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SAN JOAQUIN LOCAL T ALTH DISTRICT <br /> -'OR OFFIC SE: 1601 E. Hazelton:'Ave. ;° Stockton, Calif. <br /> Telephones,' (209)-'456 67$1 <br /> PLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Z. $ 1.�l <br /> THIS PERMITuEXPIRES rl YEAR: FROM .DATE `ISSUED' Date Issued 7L <br /> �;'M ;..• `(Complete It .Triplicate) <br /> Application_.is :hereby,made oto the ySanc,Joaquin,,Loc.al Health District for a permit to construct <br /> and/or install the work herein described. Th sc:application° is made in compliance with San Joaquin ; <br /> County -Ordinance No. -1862 and theERules, and Regulations of- the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION LL CENSUS TRA/CT `>Q <br /> Owner!s`Name.._._ _�1-YL:.S.H, f`x9-fi.LR�.eJ"' ":r 1{a. '�E: .;l''� - c,. .. - Phonexf'3,!7,yo <br /> Address 5 � J /n�� iv, .._. - - - City - <br /> _" r.. . - J. _•+ _ _ � License �� Phone ��" <br /> Contractor's Name �� / 7 <br /> TYPE_OF_WORK.m(Check) : NEW WELL / / DEEPEN '/7/ RECONDITION /_7 -DESTRUCTION /_7 <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 i1 Cable Tool Dia. of Well. Excavation �- <br /> Domestic/private i Drilled Dia. of Well Casing <br /> Domestic/public t' Driven Gauge of Casing ► <br /> -Irrigation :.{ Gravel Pack Depth of Grout Seal s <br /> Other Rotary Type of Grout a I <br /> I Other Other Information ' <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> 1 1 I <br /> PUMP REPAIR: /77 State Work Done_ <br />-,RES-T-RUCTION�.OF�-WELL.:,;..We11=Diameter-.n-, = 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 /> P 1 i �- v �� <br /> (DRAW PLOT PLANIMN REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I , <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE I I/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H-1426 4/72 <br />