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FOR QFFISAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ' CE USE: <br /> 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> ZLZELLP <br /> THIS PERMIT EXPIRES 1 YEAR FROM. <br /> DATE ISSUED <br /> (Complete In Triplicate) Date Issued _3_,2,7.T <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 /> JOB ADDRESS/L©CATION t'' <br /> - w <br /> Owner's NaCENSUS TRACT <br /> Name t d <br /> Phone :,,EO_pq <br /> Address j 11 <br /> City <br /> Contractor's Name ' <br /> V N C. � License # -�� <br /> Phone <br /> TYPE OF WORK (Check); NEW WELL DEEPEN / / RECONDITION /_7 DESTRUCTION /_' <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /? <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> jjo&l"SEWER <br /> SEWAGE DISPOSALF FIELD O LINE ES /SEEPAGE PIT <br /> OTHER <br /> INTENDED USE TYPE OF WELL <br /> Industrial CONSTRUCTION SPECIFICATIONS <br /> Domestic/private Cable Tool Dia. of Well Excavation <br /> Drilled Dia, of Well Casing <br />_ Domestic/public � <br /> Irrigation Driven Gauge of Casing <br /> Other Gravel Pack Depth of Grout Seal <br />- Rotary Type of Grout <br /> Other Other Information <br /> o <br /> PUMP INSTALLATION: Contractor <br /> r Type of ,Pump <br /> _ <br /> H.P. <br /> PUMP REPLACEMENT:.,,... / / State ,Work Done <br />'UMP REPAIR:, / / State Work Done ` <br />)ESTRUCTION OF'WELL: - .Well„Diame ter <br /> Describe Material and Procedure Approximate Depth <br /> ------------ <br /> hereby agree to comply with all laws and regulations of the San Health District <br /> nd the State of California pertaining to Joaquin Local <br /> or regulating well construction. Within FIFTEEN DAYS <br /> fter completion of.,my work on a new well, I will furnish the San Joaquin Local Health District a <br /> ELL D'RILLERS ',REPORT of - thetwell and notify them before putting the well in use. The above <br /> nformation :is true to the best of my knowledge and belief. <br /> IGNED rl <br /> - - -� _- - �- <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> 1ASE I DEPARTMENT USE ONLY <br />'PLICATION ACCEPTED <br />)DITIONAL COMMENTS: DATE <br /> PHASE II GROUT. iNSPECTION <br /> fSPECTION BY PRADATEINAL INSPECTIO <br /> INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 <br /> 7/72 IM <br />