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}; �V SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-678.1 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. — <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED , Date Issued <br /> (Complete In Triplicate) 7� / <br /> Application is hereby made to the San Joaquin Local Health District for a permit o co4struct <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 /> JOB ADDRESS/LOCATION 41702 40' ,C— A4A2 140AA4j00 CENSUS TRACT S�6 <br /> Owner's Name ��1� - K &).4 --..__. Phone 36 / p <br /> Address f C* City ' Cei�/JflOO <br /> Contractor's Name License # &&?0Z Phone3j _ <br /> TYPE OF WORK (Check) : NEW WELL '/>K 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 /> Industrial __,.,,-eable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic <br /> /public Driven Gauge of Casing �} <br /> Irrigation Gravel Pack Depth of Grout Seal /1/d�/l/1t,�u��r �?i/,•,_•—w, <br /> Other Rotary Type of Grout Sw co.!/l��P C <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> .pESTRUCTION 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 /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLS S REPORT' of the well and notify them before putting the well in use. The above <br /> informs o it to the best of my knowledge and belief. <br /> SIGNS AW TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIM) <br /> FOR DEPARTMENT USE ONLY 1 <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: 7� <br /> PHASE II GROUT INSPECTION PHASEIIFINAL INSPECTION <br /> INSPECTION BY DATE Zs_ /!y '2 1, INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H -1426 4/72 1MW <br />