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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 /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. -73-a;�3 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application ib hereby made to the San Joaquin Local Health District for a permit to construct <br /> and/or install the work herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862. and-the Rules and Regulations of the Sart Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> s 1 <br /> Owner's Name ` Phone <br /> Address kn City <br /> Contractor's Name License 17 OIO Phone <br /> TYPE OF WORK (Check): NEW WELL /_7 DEEPEN % / RECbNDI__IbR 77_:DESTRUCTION /-7 _ y - <br /> PUMP INSTALLATION / PUMP REPAIR / / PUMP REPLACEMENT /�- <br /> Other -- <br /> ` { <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE T TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Indus'.trial `� Cable Tool Dia.. of Well Excavation <br /> Domestic/private ,f< Drilled . Dia. of Well Casing <br /> Domestic/public W Driven Gauge of Casing ! <br /> I Irrigation �.,, -`i Gravel Pack Depth of Grout Seal = <br /> Other Rotary Type of .Grout <br /> , r Other Other Information b .: <br /> PUMP INSTALLATION: Contractor - a , <br /> Type_of-Pump �_ .... __,_.. � H.P. <br /> PUMP REPLACEMENT: /ZKState Work Done <br /> PUMP REPAIR: j /. State Work Done <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 /> i 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 /> f WELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> information is true to the be t of my knowledge and belief. <br /> SIGNED TITLE ti <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> i <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: i <br /> PHASE II GROUT INSPECTION PHASE II/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 <br /> 7/72 1M - �,, <br />