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FOR bSAN JOAQUIN LOCAL HEALTH DISTRICT t r <br /> r FFTCE USE:-j, 1601, E. Hazelton Ave. Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> LICATION FOR WELL CONSTRUCTION OR PUMP PERMITPermit No. 74 AU <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED Date.Issued . al 7� <br /> t (Complete In Triplicate) <br /> Application is her by-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 incompliance with San Joaqui <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION ZD s <br /> CENSUS TRACT <br /> g Owner's Name' <br /> Phone <br /> Address <br /> City .. <br /> Contractor's Name <br /> k _ <br /> JPX License V hone y <br /> TYPE OF WORK (Check): NEW WELL DEEPEN /? RECONDITION /? DESTRUCTION /7 <br /> PUMP INST /LATION / PUMP REPAIR / / PUMP REPLACEMENT /? <br /> Other. / / <br /> DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES PIT PRIVY <br /> SEWAGE'DISPOSAL FIELD <br /> CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATION <br /> Industrial - -Cable-Tool Dia, of Well Excavation S <br /> Domestic/private _ Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> ' Irrigation <br /> Gravel Pack Depth of Grout Seal • <br /> Other Rotary Type of Grout <br /> i Other Other Information <br /> PUMP INSTALLATION: Contractor i <br /> 14- <br /> C, � <br /> Type of Pump <br /> H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: State Work Done <br /> ,RESTRUCTION- OF WELL: Well Diameter -- <br /> Describe Material and Procedure Approximate Depth n <br /> i <br /> �r <br /> s 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 <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 /> inform o is true to the best 4 my knowledge and belief. <br /> r <br />� SIGNED <br /> TITLE <br /> 41'' (DRAW PLOT LAN ON REVERSE SIDE .• <br /> k FOR DEPARTMENT USE ONLY <br />�PHASE I . <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: / DATE a/ L I <br /> .km <br /> PHASE II GROUT INSPECTION <br /> INSPECTION BPHASE III FINAL INSPECTION 1 <br /> Y � � DATE _ INSPECTION BY- DATE •71 <br /> CALL FOR A GROUT. INSPECTION,.PRIOR TO- GROUTING AND FINAL INSPECTION. <br /> E €3 1426 ` <br />'�' - 7/72 1M ! <br />