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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. - <br /> THIS <br /> o. -THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date IssuedL3 <br /> °�� d yT•, ," fk 4s L ;:"Liv:, (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 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION <br /> , SUS TRACT z?-q i10 Z-V <br /> Owner's Name IC Phone <br /> Address 3 S - -- ISr <br /> all City =2,cy <br /> Contractor's Name License 41 1,1j Phone <br /> 212W. <br /> TYPE OF WORK (Check) : NEW WELL /% DEEPEN. /_7 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 i <br /> ,R <br /> INTENDED USE 1M TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool' ' Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing, f.3 <br /> . Domestic/public Driven } F Gauge of Casing <br /> Irrigation I� Gravel Pack Depth of Grout Seal' r` <br /> Other N Rotary Type of Grout J <br /> A Other Other Information - <br /> .PUMP INSTALLATION: Contractor ``'� � r ✓ - <br /> r <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ji? State Work Done77 <br /> PUMP REPAIR:- - _ State''Work <br /> s _/: /—.- "Dane "T <br /> EUCTION OWELL: Well Diameter s� �. <br /> -� STRF-• _ -- -, '� Approximate Depth <br /> k 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 DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> information i- true to the best of my knowledge and belief. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) � —�- <br /> s FOR DEPARTMENT USE ONLY <br /> PHASE I / <br /> APPLICATION ACCEPTED BY DATE b /1Y'. 'jam <br /> ADDITIONAL COMMENTS: 41Z vt <br /> PHASE II GROUT INSPECTION P / II AL INSPECTION <br /> INSPECTION BY DATE INSPECTIONBY DATE ZZ 3 . <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 IM <br /> it r <br />