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SAN JOAQbIN LOCAL 'HEALTH DISTRICT ; <br /> FOR,OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Ca11 f. <br /> -r - 1 Telephone: (209) 466-6781 <br /> f APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> ' THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued .� G <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 madel'in compliance with San JoaquiY <br /> County Ordinance No. 1862 and' trhe Rules and Regulations o the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name � - �� �� Phone <br /> Address _ �-- �Lyf0flW,,401 City <br /> Contractor's Name License # jf3 7yj7Phone y <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN / / RECONDITION DESTRUCTION /-7 <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 SPECIFICATIONS66 <br /> f Industrial Cable Tool Dia, of Well Excavation S <br /> k _ 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 /> PUMP INSTALLATION: Contractor <br /> Type of Pump --- �- H.P. / <br /> PUMP REPLACEMENT: State Work DoneXA <br /> PUMP REPAIR: / / 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 regulating well construction. Within FIFTEEN DAYS <br /> rafter 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 my knowledge—and belief. <br /> o SIGNED ,, TLE <br /> W LOT PLAN ON REMRSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY ✓ DATE •�-7 <br /> . ADDITIONAL COMMENTS: V: <br /> PHASE II GROUT INSPECTION PHASE II FINAL INSPECTION <br /> k INSPECTION BY DATE INSPECTION BY DAT/E_ <br /> CALL FOR A GROUT INSPECTION S .PRIOR TO GROUTING AND FINAL INSPECTIO `�`� <br /> E H 1426 7/72 IM ; <br />