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f <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ffR 0 ICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephoner (209) 466--6781 <br /> APPLICATION FOR WELL' CONSTRUCTION OR PUMP PERMIT Permit No. - L <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 apermit to construct <br /> and/or install the work herein described. This application is made in compliance- with San Joaquin. <br /> County Ordinance No.' 1862 aha -the Rules and Regu ations .cif the San .Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION n-ZZ1b)777 <br /> CENSUS TRACT <br /> E Owner's NamePhPh <br /> one <br /> Address �.. 'Cit-y ' f <br /> _ <br /> E. Contractar's_.Name. ._ /�/ icee se ! -Lhon � <br /> i <br /> f TYPE OF WORK (Check) : NEW WELL DEEPEN /7/ RECONDITION /_7 DESTRUCTION /`7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other!/ / <br /> DISTANCE TO NEAREST:. SEPTIC'TANK SEWER LINES PTT PRIVY <br /> SEWAGEIDISPO AL FIELD CESSPOOL/SEEPAGE PIT OTHER "4 <br /> A <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial I Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing I <br /> Irrigation Gravel Pack Depth of Grout Seal F <br /> Other Rotary Type of Grout _� -7� <br /> Other Other Information . .•__. (S <br /> I <br /> PUMP INSTALLATION: Contractor <br /> Type if Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> .PESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> s <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> i 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 i true to the be of my knowledge and belief. <br /> SIGNED TITLE r <br /> (D PLOT PLAN ON REVERSE S1 <br /> FOR .DEPARTMENT USE ONLY <br /> PHASE p <br /> OMAPPLICATION ACCEPTED BY , DATE <br /> iADDITIONAL CMENTS: , 1 - . IAI <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> ( INSPECTION BY DATE 7-1-73 INSPECTION BY DATE - 7 <br /> CALL FOR A GROUT INSPECTION .PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H-1426 7/72 1M <br />