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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 CONSTRUCTIOVOR PUMP PERMIT Permit No. -Z?--73 Y <br /> THIS PERMIT EXPIRES ,l '.YEAR `FRIOM ZATTE 1S SUED '-.--Date Issued <br /> P"'. (c6mp- let'6 Ift-Tripliclate <br /> ApplicataoriU-6-,hereby--made ito t-heii-S,Ianc.Joaqu3*.ln,',:Lo&alt HdalfhDistrict-'forsa�perm t't'to -coAstrdcif <br /> and/or install the work herein described. Thig-�:application,,is'-'made-,Iin�.compl.'ia:nce with-San"Joaquin <br /> County t..O,rdinan'ce-,-N.o.-:,1862;r.and,Flth.dRu•les!.,-andl-Re,gulatl:,o'tip,,of(,.the San lJoaquin,Locali-:He'alth 'Distrlct <br /> JOB ADDRESS/LOCATION <br /> CENSUS,TRACT <br /> Owner�d!>NameMY. A <br /> . Address Iq/�7 -,3-pA City-. <br /> Contractor's Name <br /> License # 1;2o _ Phone ' T'3 el, 73`7& <br /> V <br /> .'­TYPE�OF WORK (Check) : : NEW WELL DEEPEN ' 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 /> j INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation.. <br /> I Domestic/private, Drilled Dia. of Well Casing Ar <br /> Domestic/publid DrivenGauge of' Casing <br /> Irrigation Gravel Pack : Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: ' Contractor <br /> Type of `Pump H.P. , <br /> PUMP REPLACEMENT: State Work Done <br /> PUMP REPAIR: State Work Done A­ <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulatiqps 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 wor:k' on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notify them beforie putting the well in use. The above <br /> information is true to the best :of my knowledge and belief. <br /> SIGNED TITLE <br /> V (DRAW PLOT PLAN ON REVERSE SIDE-) <br /> DEPARTMENT USE ONLY <br /> PHASE I r <br /> APPLICATION ACCEPTED BYLJ DATE <br /> ADDITIONAL COMNENTS: <br /> PHASE II GROUT INSPECT ON <br /> =IJLI/ INAL INSPECT N <br /> INS'PiECTION BY DATE INSPECTION BY U DATE CA_ LLFOR A GROUT n7dYE"CYI'(?NP'K-I-O'R-TOG- ING AND -FINAL.,.INSPECTION. <br /> E H 1426 4/72 1M <br />