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SAN JOAQUIN LOCAL �iEALTU. DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 4666781 <br /> "o .APPLICATION FOR WELL CONSTRUCTION OR PUMP PERNMIT Permit No. .,.9,,1- �J <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued <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 and the Rules and Regulations of the San Joaquin Local. Health District. <br /> y <br /> JOB ADDRESS/LOCATION Z CENSUS TRACT <br /> Owner's Name �. 1 t 14leo„ n4+r� _' _ Phone S� ii <br /> Address 4 .7 . t19_ .�-�.�r.. City � 7acai) <br /> License <br /> Contractor's Name ���' �°�� � Q{ 30_ , <br /> hone <br /> TYPE OF WORK (Check) : NEW WELL/DEEPEN 17 RECONDITION /-7 DESTRUCTION /-7 <br /> PUMP INSTALLATION /tyf' PUIQ REPAIR / / PUMP REPLACEMENT /7 <br /> Other /-7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES (a_. PIT PRIVY <br /> SEWAGE DISPfl TOTIELD CESSPOOL/SEEPAGE PIT OTHER <br /> f <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation -a g n <br /> Domestic/private Drilled Dia. of Well Casing _ /�,'• <br /> : �omestic/public Driven Gauge of Casing <br /> Irrigation ravel Pack Depth of Grout Seal �(�+ P4- <br /> Other <br /> fOther _je'lotary Type of Grout Cowc.ts t�t 51uefy <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump _ "7`u r .v e H.P. - <br /> PUMP REPLACEMENT: / J State Work Done <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 /> 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 my knowledge and belief. <br /> SIGNED ' TITLE <br /> (15—RAW TLOT PLAN ON REVERSE SI1D4E4 <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE �g <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL F'OR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 4/72 1M <br />