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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. may_z rJ <br /> THIS PERMIT EXPIRES 1 YEAR FROM BATE ISSUED Date Issued �� <br /> (Complete In'Triplicate) po,7 01810 - 2_0 <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/LOCATT Wy, �� �,w� CENSUS TRACT <br /> 11 <br /> Owner's Name � � <br /> Phone 16 '--�_ <br /> Address11 -� .3 6 City <br /> Contractor's Name License #I .LM Phone .0 <br /> TYPE OF' WORK (Check): NEW WELL DEEPEN /_/ RECONDITION /? DESTRUCTION /`7 <br /> ' PUMP INSTALLATION R PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> Other / / — — <br /> O <br /> DISTANCE TO NEAREST: SEPTIC TANK O <br /> SEWER LINES PIT PRIVY W <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL <br /> CONSTRUCTION SPECIFICATIONS <br /> Industrial _ Cable Tool Dia. of Well Excavation /-"� �� <br /> _ Domestic/private Drilled Dia, of Well Casing <br /> D'bmestic/public Driven Gauge of Casing <br /> 171 Irrigation Gravel Pack Depth of Grout Seal <br /> Other <br /> Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> r- Type of Pump H.p, <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR. / / State Work Done <br /> ETRUCTION OF ELL: Well Diameter <br /> � SW <br /> _ Approximate Depth <br /> 1 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 rue to the be t of my knowledge and belief. <br /> SIGNED -.1-j TITLE <br /> _ DRAW PLOT PLAN ON REVERSE SIDE FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE IIIFINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE I,� <br /> CALL,:F'OR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E Ti 1426 7/72 1M <br /> i <br />