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SAN JOAQUIN LOCAL HEALTH DISTRCT <br /> FOR OFFICE USE: 1601 E. Hateltgn Ave.', Stockton, Calif. N <br /> Telephone: (209) 466--6781 <br /> PLICATION FOR WE LL'CONSTRUCTION OR PUMP PERMIT Permit No. <br /> -75 <br /> THIS PERMIT EXPIRES 'I YEAR FRAM DATE ISSUED ` <br /> Date issued <br /> A (Complete In Triplicate) <br /> Application- is-here <br /> is here made to 'the 'San `Joaquin 'Local Health bistrict fot 'a permit to construct <br /> and/or install the work herein described. This application is made <br /> County Ordinance Na. "1862 and the Rules and' Regulations of the San Joaquin pL'ocallanceHeal h with SDistrict. <br /> JOB ADDRESS/LOCATION j^ A <br /> 36 <br /> , <br /> . .. a. . CENSUS TRACT <br /> ' 4 <br /> Owner's Name' <br /> Phone <br /> Arldress, 74 <br /> - <br /> . <br /> Contractor's Name <br /> License # Phone - <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN / / RECONDITION /7 DESTRUCTION /_ <br /> AL ' <br /> PUMP INSTLATION PUMP REPAIR / PUMP REPLACEMENT /? <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER LINES PIT PRIVY <br /> SEWAGE. DISPOSAL FIELD CESSPOOL/SEEPAGE PITI <br /> OTHER <br /> INTENDED USE TYPE OF WELL i <br /> Industrial CONSTRUCTION SPECIFIGATIONS <br /> _ Domestic/private Cable Tool Dia. of Well Excavation <br /> Drilled Dia. of Well Casing <br /> Domestic/public Driven <br /> .�� Irrigation Gauge of Casing , <br /> Gravel Pack <br /> Other Depth of Grout Seal <br /> � <br /> Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of-Pump <br /> _ H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR-: - = / State Work Done <br /> ESTRUCTION OF WELL: Well Diameter <br /> I hereby agree to compDescribe Materia]. and Procedure Approximate Depth ' <br /> ly 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 i <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 , <br /> t- TITLE <br /> (D PLOT P ON REV RSE SIDE <br />?RASE I FOR DEPARTMENT USE ONLY <br /> i'P CATION ACCEPTED BY <br /> IDDITIONAL COMMENTS: DATE _ <br /> PHASE II GROUT INSPE ION <br />:NSPECTION BY DATEPHASE III FINAL INSPECTION f <br /> INSPECTION BY DATE <br /> CALL A GROUT <br /> E H 142626 .,INSPECTION-PRIOR. TO GROUTING AND FINAL .INSPECTION, � <br /> 7/72 Im <br />