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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 /> PLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. . <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 7 2_ <br /> (Complete In Triplicate) prr p� cf <br /> Appl4ctz,�- <br /> ion i h reby made toAt e San Joaquin Local Health District for a permit to constt`uct <br /> and/or install the work herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 and then"Rules .anC-Regulations .of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION Imo ( L 4ij CENSUS TRACT <br /> e i <br /> Owner's Name Dfp Phone <br /> Address '� 8 l �.�-� ►7 City <br /> Contractor's Name o B License # 3 j. hone <br /> TYPE OF WORK (Check) : NEW WELL /_7 DEEPEN /% RECONDITION /_7 DESTRUCTION /_7 Hyl <br /> PUMP INSTALLATION / / PUMP REPAIR Y/ PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK A 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 /> X_ Irrigation Gravel Pack Depth of Grout Seal r <br /> Other Rotary ' Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION." Contractor a „� <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: /X/ State Work Done ! 14, &M 43 �j fl <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 f <br /> information is true to the best <br /> o knowledge—and belief.. <br /> SIGNE lc� ITLE <br /> D PLOT AN ON ERSE SIDE r <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I � <br /> 0V <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: — 1 <br /> PHASE II G 0 N P ION PHASE I N NSPECTION <br /> INSPECTION BY DATE INSPECTION BY _ j DA J <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPA <br /> E H 1426 7/72 1M <br />