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1/ SAN J'OAQUIN LOCAL HEALTH DISTRICT <br /> r FOL;OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> ' APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.-, 2_ p <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued /-73 <br /> (Complete ,In Triplicate) <br /> Application is 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 San Joaquin Local. Health District. <br /> f � <br /> ('71 —Z( <br /> JOB ADDRESS/LOCATIONT t ,w C �°i $ CENSUS TRACT <br /> f f <br /> O �... r_ -- _ Phone <br /> wner's Name � ,.�.y _.r.�r�,e-_.r e!, <br /> Address _ rE_ <3 �1 i ? City C�lc?'! <br /> s- <br /> Contractor's Name `� 1�/ �/i License # 37rj Phone 1-74 (, <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN/ / RECONDITION / / DESTRUCTION 17 <br /> PUMP INSTALLATION / J PUMP REPAIR / PUMP REPLACEMENT /-7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TALK SEWER LINES PIT PRIVY <br /> _.. .` SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> Q <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> X Domestic/private Drilled Dia. of Well Casing . <br /> r Domestic/public Driven Gauge 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 "' 1 s /e '"4 H.P. <br /> PUMP REPLACEMENT: / / State Work Done' <br /> PUMP UPAIR: / State Work Done ' o UaA/& <br /> V IV <br /> ,DF(ZTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply iurith 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 /> I 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 owledge an elief. <br /> i <br /> SIGNED TITLE <br /> x ( LQ PLAN ON R R5E SIDE) <br /> . FOR DEgARTWNT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED .BY P Y DATE <br /> ADDITIONAL COMMENTS: E <br /> PHASE II GROUT INSPECTION PHA III/FI—NAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL. FOR A GROUT INSPECTION -PRIOR TO GROUTING AND FINAL- INSPECTN. <br /> E H 1426 \.. _ ` c4/711m <br />