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O L' SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: /1,601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR .WELL CONSTRUCTION OR PUMP PERMIT Permit No. 73 - lop <br /> THIS PERMIT'yEXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> f ..(Complete In Triplicate) <br /> Alication is hereby made to the San '7oaqui.n Local Health District for a permit to construct <br /> .Aiid/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 /> JOB ADDRESS/LOCATION / �riE_ ►�I/u ' - CENSUS TRACT <br /> Owner t s Name Phone <br /> Address City <br /> Contractor's Nam License Phone i2 <br /> jot <br /> ( TYPE OF WORK (Check) : NEW WELL / / DEEPEN / RECONDITION /� ,DESTRUCTION ',/� 1`5 <br /> I <br /> PUMP INSTALLATION /`/ PUMP REPAIR /[/-PUMP REPLACEMENT__ /_7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES` PIT PRIVY <br /> k SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> 1 INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS ' <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 <br /> -- � Other Other Information _ <br /> PUMP INSTALLATION: ' Contractor <br /> TYPe of PH.P. <br /> PUMP REPLACEMFtNT: / -/- State Work Done <br /> PUMP `REPAIR: �(.i' State Work'"Dane" - • �,� -- __. - -� <br /> s <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 /> l information is true to the best of my knowledge and belief. <br /> TITLE <br /> SIGNED L <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE _ <br /> APPLICATION ACCEPTED 'VGT <br /> ADDITIONAL COMMENTS: I INAL. INSPECTI <br /> PHASE IINSPECTIONDATEi. INSPECTION BY ATE INS " <br /> COLI, FOR A GROUT INSPECTION PRIOR TO GROUTING AND..FINAL INSPECTION. 7/72 1M <br /> i E H 1426 <br />