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SAN JOAQUIN LOCAL HEALTH DISTRICT <br />` FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 1 3-k�a <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued. H - ki --7� <br /> (Complete In Triplicate) <br /> Application- is hereby made to the 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 aiid the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION _ CENSUS TRACT <br /> Owner's Name a A) Phone D <br /> Address <br /> f�,U( City . C <br /> _ )��-- --- <br /> Contractor's Name 7 ALJ License Phone , }� <br /> h . <br /> F TYPE OF WORK (Check) : NEW WELL / T DEEPEN / / RECONDITION /7 DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <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 /> ' 4 k.Industrial I Cable Tool° Dia, of Well Excavation <br /> 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 /> f Other Other Information <br /> 4 4s� <br /> PUMP INSTALLATION-. Contractor <br /> Type of Pump H.P. <br /> PUMP-REPLACEMENT. / CP State Work Done <br /> �y <br /> PUMPREPAIR:.-•.-�- :/�./ .r,s,�--—.- . .�.�.. •.;-.,.....-.. , <br /> �. -�=�- State"'Work Done <br /> ! ,DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe 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 rekulating 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 /> WELL DRILLERS REPORT of the well and notify them before putting the well in use. . The above <br /> information is true to.the best of m knowledge and belief.' <br /> 4SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> 4 _ <br /> PHASE I <br /> APPLICATION ACCEPTED BY 1" _ DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASF, III/FINAL INSPECT N <br /> , INSPECTION BY _ /C_ DATE Y DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />