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SAN J0'AQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Razelton Ave. , Stockton, Calif. <br /> Telephone:: <br /> p (209) 466-6781 � <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Z,?-,//,fvv <br /> f <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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 /> 1 215 <br /> JOB ADDRESS/LOCATION �f CENSUS TRACT <br /> Owner's Name <br /> Phone 'r <br /> •- <br /> Address City <br /> Contractor's Names <br /> - / � , e If �) r _ License # ,M Phone _ C� S1 �jC�r <br /> � e <br /> ~TYPE OF WORK (Check) NEW WELL DEEPEN / / RECONDITION /7 DESTRUCTION /-7 <br /> PUMP INSTALLATION / / "PUMP REPAIRF/ / PUMP REPLACEMENT /_7 - <br /> Other — <br /> i <br /> DISTANCE TO NEAREST: �-SEPTIC TANK SEWER LINES PIT PRIVY .. <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE�PIT OTHER <br /> INTENDED USE ✓ TYPE OF WELL _ <br /> �- ,`E� CONSTRUCTION SPECIFICATIONS J <br /> _ Industrial x Cable Tool Dia. of Well .Excavation lr <br /> Domestic/private- Drilled Dia. of Well Ca'sing•� k <br /> Do public Driven Gauge of Casing `. <br /> Irrigation { Gravel Pack Depth of Grout Sea <br /> Other ,. -Rotary Type of Grout <br /> Other ``� Other Itiformation t <br /> 3 � <br />,,PUMP"INST'ALtATIONo• __ -Contractor - <br /> Type of Pump <br /> H.P. 1 <br /> PUMP REPLACEMENT: / / State Work Done <br /> 4 <br /> PUMP REPAIR: / / State Work Done <br /> ESTRUCTION 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 ,re.gulating.well.construction.,---Wi.thin-FIFTEEN. DAYS I <br /> after coc�pletfon 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 Cd. <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SID <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I =73 <br /> APPLICATION ACCEPTED DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHA III/FINAL INSPECTION <br /> INSPECTION BY DATE _ INSPECTION BY DATE !V-/7- 72 <br /> CALL FOR A GROUT .INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. , � J <br /> E H 1426 ' w 7/72 1M k_10 <br /> Y -'d' <br />