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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.T3-/3a <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 3-- 773 <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 Sax: Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the. San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATIONCENSUS TRACT Cy 7 <br /> Owner's Name ,ee 2Z 92 <br /> e,>§ Phone <br /> Address City <br /> Contractor's Name _D- -s, License # /5/ ,j6Phone pgs <br /> TYPIC OF WORK (Check): NEW WELL -/-r DEEPEN j_? RECONDITION /-7 DESTRUCTION /-7 — — <br /> PUMP INSTALLATION / / PUMP REPAIR / /PUMP REPLACEMENT /7 <br /> Other f-1 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS rt <br /> Industrial /' Cable Tool Dia, of Well Excavation � <br /> 1/ Domestic/private Drilled Dia. of Well Casing <br /> rr <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 T <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: /-7 State Work Done <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 /> information is true to the best of my knowledge and belief. <br /> SIGNED,2�) ,,,.,4.. TITLE <br /> (DRAW LOT PLAN ON REVERSE SID �rt"_ <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> r <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE 3 INSPECTION BY DATE 3 /d-73 <br /> CALL FOR A.GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M � <br />