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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelt6n"A:vL .-L­Stockton, Calif. <br /> Telephon6­- '(204) 466-6781 <br /> APPLICATION FORYELL`-'CONSTRUCTION OR PUMP. PERMIT Permit Nob <br /> THIS',IPERMIT- :EXPIRE-S"(i'YEAR-')FROg DATE ISSUE'D''*' 'da'te' I'ssued s_�P -72 <br /> (Cqi'mipildto ln­Triplic'ate) <br /> 6al- Health Dis`t�rct 'f or ,a"perm"it to construct <br /> Applicati6n 'is'-hereby'ma-d,-6��,to-5tli6'�-San "-Joaqbin'Lo"' <br /> i ' <br /> and/or install the work herein described. -IT-his'- appapplication1i <br /> s made h c omp iance ith San Joaquin <br /> County "Ordinance 'Nd'. -1862.And- the rRiiles 'aihid`ke u"Idtions of the San "Joaqui6 Local &altli District. <br /> , <br /> JOB ADDRESS/LOCATION IfAl h _A Ao CENSUS <br /> SUS T <br /> RACT <br /> or. j_," -,- ML <br /> owner"6 Niiiiie Phone <br /> Address A1.0 -,City <br /> Contractor's Name- License -Phone � <br /> TYPE OF WORK (Check) ; NEW WELL Ap","DEEPEN RECONDITION /_7 DESTRUCTION /77 -7 <br /> PUMP INSTALLATION PUMP REPAIR REPLACEMENTPUMP REPLACEME <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial ,Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven a Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contiractor <br /> Type, of Pump <br /> PUMP REPLACEMENT- state Work Done <br /> I.PUMP�-REPAIR:­, /_7 state' Woik`Doi4f <br /> k jDESTRUCTION OF WELL: Well. Diame'ter Approximate Depth <br /> Describd Material and Procedure <br /> I hereby agrde to comply withiall laws and regulations of the San Joaquin Local Health District <br /> sand the State ,of California' )extaining 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 /> lWELL DRILLERS REPORT of the -well and notify them before putting the well in use. The above <br /> information i true to the best of my knowledge and belief. <br /> SIGNED <br /> &A A A TITLE <br /> zxlu <br /> OF! <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL, INSPECTION <br /> INSPECTIWBY DATE INSPECTION BY zkz DATE <br /> CALL FOR .A.GROUT7INSPECTION PRIOR TO 'GROUTING AND FINAL INSPECTION. 7/72 1M <br /> E'-H 1426 <br />