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i <br /> FOR OFF _ SAN JOAQUIN LOCAL HE <br /> ICE USE: 1601 E. Hazelton Ave,HEALTH DISTRICT <br /> ,7-el-e-- , Stockton, Calif, <br /> 7a.- Telephone : (209) 466-6781 <br /> .. APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. _ <br /> 1 3� <br /> THIS PERMIT EXPIRES 1 YEAR -FROM DATE ISSUED <br /> a - c bate Issued <br /> .Application is hereb � ' - (Complete In Triplicate) <br /> y .made to the San Joaquin Local Health District for a <br /> and/or install Lo* <br /> the work herein described. permit to construct <br /> County Ordinance No. 1''62 and the Rules and Regulations of the San .Toa uiri Loc <br /> PPlf�ation is made in compliance with San Joaquit <br /> 9 a1' Health District. <br /> JOB ADDRESS/LOCATION <br /> CENSUS TRACT -2vZ <br /> Owner's Name � � °- - <br /> Phone <br /> Address <br /> yob <br /> Contractor's Name City <br /> Ij License # <br /> Phone <br /> TYPE OF WORK (Check) : NEW WELL /-7 DEEPEN <br /> CIT RECONDITION 1-7 DESTRUCTION <br /> 'UMPA <br /> P INSTALLATION / / PUMP REIR / / PUMP REPLACEMENT <br /> Other /% ��: - /-7 <br /> DISTANCE TO NEAREST: I� h <br /> SEPTIC TANK SEWER LINES I1 PIT pRzi,Y <br /> SWAGE DISPOSAL FIELD .!^ <br /> CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL Ij <br /> Industrial I� CONSTRUCTION SPECIFICATIONS <br /> Domestic -�__ Cable Tool Dia.1, of Well Excavation <br /> /private � f <br /> Domestic/public Drilled Dia.! of Well Casing <br /> _ Irrigation ----__ Driven Gauge of Casing <br /> Other Gravel Pack Depth of Grout Seal r <br /> j� �_ Rotary Type'�of Grout i <br /> OtherOther Information <br /> PUMP INSTALLATION: <br /> Contractor <br /> Type of Pump <br /> H.P. <br /> PUMP REPLACEMENT: / I�°/ State Work Done � <br /> LqL REPAIR: IN� <br /> /T/ State Work Done <br />,DESTRUCTION OF WELLS Wekll Diameter ( 41 f{. <br /> Approximate Depth <br /> De�tribe Material and Procedure I� Lo <br /> I hereby agree to comply tiiil. <br /> and the State of laws California pertaining todoreregulatingat ns o1relleSan Joaquin construction.LeWit Health District <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 i hie FIFTEEN DAYS <br /> information is '� <br /> to thef best of my wledge and belief. n use. The above <br /> SIGNED 1! <br /> ' TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br />'HASE I FOR DEPARTMENT U_SE ONLY <br /> FPLICATION ACCEPTED BY II <br /> J)DITIONAL COMMENTS: rt '+° DATE I <br /> t a� , <br /> PHASE II GROIT INSPECTION PHAS I IFI AL INSPECTION <br /> NSPECTION BY IM, DATE <br /> INSPECTION BY DATE <br /> CALL ,FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL <br /> E H 1426 i. INSPECTI <br /> 7/72 lm <br />