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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FoF_.OrICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone t (209)466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.��c� yQ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued <br /> (Complete In Triplicate) Z.SS- Z?ar.,Q.6 <br /> Application is hereby made _oYthe San Joaquin Local Health District for a permit to construct <br /> and/or install the work herein described. - This application is made In compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health 'District. <br /> C y � <br /> JOB ADDRESS/LOCA'T'ION ay. CENSUS TRACT- <br /> 'Owner I a <br /> RACT.'Owner's Name Phone - <br /> Address D City. . <br /> Contractor's Name License # Phone . -2 S <br /> TYPE OF WORK (Check): NEW WELL '/ / DEEPEN -1-7 RECONDITION '/-7 DESTRUCTION /_77 <br /> PUMP INSTALLATION �/ PUMP REPAIR / / PUMP REPLACEMENT /? a, <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER �^ <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> R Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> i <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. . <br /> PUMP REPLACEMENT. / / State Work Done. <br /> :i 'PUMP UPAIR: / / State'Wo'tk Done - -.•�_ _ .�� __ <br /> l; pFCTRUCTION OF WELL: Well Diameter _ -- -- Approximate Depth <br /> hDescribe Material and Procedure <br /> I hereby agree to comply with all laws and regUlations of the San Joaquin Local Health District <br /> and the State of California pertaining to or regulating well 'construction. Within FIFTEEN DAYS . <br /> after completion of my work on a new well., I will furnish the San Joaquin Local Health District a <br /> } WtLL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> I ififormation is true to the best of my ka6wledge and belief. <br /> SIGNEDTILE <br /> (DRAW PLM L. PLAN ON REVERSETSIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATIpN ACCEPTED ;BY z I" ' J DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION SPECTION <br /> ` INSPECTION BY DATE INSPECTION BY DATE <br /> . CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INS ON. <br /> -5-/73,x,1"1 - <br />