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w� <br /> oSAN JOAQUIN LOCAL HEALTH DISTRICT / o <br /> FOk OFFICE USE: 1601 E. Hazelton Ave. Stockton Calif. <br /> Telephone: (209) 466-6781 <br /> ,APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. z..// P <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> y (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/LOCATIONn,r I e-- CENSUS TRACT res f 30--o6 <br /> I�Owner's Name ' <br /> I — Phone <br /> A <br /> Address eip6 . '_4 2 � u�.r --- city <br /> Contractor's Name �� , a � License # l�;hone .� <br /> n <br /> TYPE OF WORK (Check) : NEW WELL /7 DEEPEN -/7 RECONDITION /-7 DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR R/ PUMP REPLACEMENT /7 <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 Cable Tool Dia.- of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing = <br /> Domestic/public �, Driven Gauge of Casing <br /> Irrigation j` Gravel Pack Depth of Grout Seal { <br /> Other Rotary Type of Grout C <br /> 'f Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump D ✓ r1 ar '� H.P. l r-- <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: State Work Done -- `, t <br /> I <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 I <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 ofj';the well and notify them before putting the well in use. The above <br /> information is true to the best of my knowledge and ief. <br /> SIGNE TLE £ <br /> II (DRAW L ON REV SE SIDE <br /> DEP T NT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS FI AL INSPEC IO <br /> INSPECTION BY 4 DATE INSPECTION BY DAT <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECT N. <br /> E H 1426 _ 7/72 1M <br />