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/ N JOAQUIN LOCAL HEALTH DISTRICT <br /> _OR OFFICE USE: � 160%wE. h.azelton Ave. , Stockton, Calif.Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> may_ 1.2 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued - y_74/ <br /> (Complete In Triplicate) <br /> -plication is hereby made to the San Joaquin Local Health District for a permit to construct <br /> .nd/or install the work herein described. This application is made in compliance with San Joaquin <br /> 'ounty Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> -�B ADDRESS ON �SS%J -v' CENSUS TRACT <br /> ner's Name , ��,j' '(��2 Phone <br /> iadress City <br /> 1 <br /> _retractors Name S l �/e-��i7S License62 <br /> d Phone <br /> PE OF WORK (Check) : NEW WELL j' DEEPEN /_/ RECONDITION /_/ DESTRUCTION /- _ <br /> .� PUMP INSTALLATION X PUMP REPAIR / / PUMP REPLACEMENT <br /> Other / / <br /> STANCE TO NEAREST: SEPTIC TANK _�Z SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD Nd)VCES�SS 0OL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> -' Industrial Cable Tool Dia. of Well Excavation <br /> y Domestic/private X Drilled Dia. of Well Casing <br /> _ Domestic/public Driven Gauge of Casing f, �r <br /> Irrigation Gravel Pack Depth of Grout Seal - U <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> ►iMP INSTALLATIONS Contractor <br /> Type of PumpH.P_ <br /> UMP REPLACEMENT: / / State Work Done <br /> _„`iP REPAIR: / / State Work Done <br /> `'STRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> I the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> rter completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> ELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> Formation is t ue to the best of my knowledge and belief. <br /> IGNEDTITLEntil <br /> (DRAW PLOT PLAN ON REVERSE SIDE) . <br /> FOR DEPARTMENT USE ONLY <br /> RASE I <br /> PPLICATION ACCEPTED BY f�, r r_ - -` DATE 1�7 <br /> JITIONAL COMMENTS: y <br /> PHASE II GROUT INSPECTION PHASE II FINAL INSPECTION <br /> NSPECTION BY 1, 1 . DATE %-l- ' -' INSPECTION BY DATE 7zl <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. �� <br /> _ E H 1426 7/72 1M <br />