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SAN JOAQUIN LOCAL HEALTH DISTRICT *� <br /> FOR OFFICE USE; 1601 E. Hazelton Ave Stockt.o- , Calif. <br /> Telephone (209) 466-6781- <br /> PLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 72--Y'3 <br /> THIS PERMIT-,,EXPIRES l. YEAR FROM DATE 'I"SSUED Date Issued 8- 7-_7 ?,- <br /> . (Complete <br /> - 77i. (Complete In Triplicate) <br /> Application is he eby made- to the.-San-Joaquin Local Health District for a permit to construct <br /> and/or install th work herein described. ' This application is made in compliance with San Joaquin ; <br /> County ,Ordinance No. 1862 and .the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION Q CENSUS TRACT <br /> Owner's Name. Phone - 41 <br /> ., i <br /> Address cx City r. /40 <br /> Contractor's Name *C.� License #/�2Phone oZ - 76 7 <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN /_% RECONDITION /_/ DESTRUCTION /- <br /> PUMP INSTALLATION / I PUMP REPAIR/ / PUMP REPLACEMENT /X7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS j <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> ' Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout m i <br /> Other Other Information <br /> PUMP INSTALLATION: Contractorti <br /> ._. Type of Pump 0;,i ,r S H.P. <br /> PUMP REPLACEMENT; State Work Done <br /> 1,W' <br /> _ U <br /> PUMP REPAIR: / / 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 /> 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 <br /> information is true to the best of my knowledge and belief. <br /> SIGNED 841) e TITLE <br /> (DRAW PLOT PLAN ON REVERSE "SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I " <br /> APPLICATION ACCEPTED BY ��, DATE 7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTIO . <br /> E H 1426 4/72 1M �j } <br />