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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOI. OIi?ICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.Z3-.5K3 4) <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED pate Issued //-7-,7S <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 <br /> the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION � CENSUS TRACT <br /> 'Owner's Name '�� �. Phone 301der <br /> Address YO ! �' City C/fY1 <br /> f 7 <br /> Contractor's Name �1��� � �r � �. License # Phone �9 <br /> TYPE OF WORK (Check): NEW WELL DEEPEN '/ / RECONDITION / / DESTRUCTION /? <br /> PUMP INST LATION X' _PUMP REPAIR f / PUMP REPLACEMENT /_7' <br /> Other /_7 <br /> DISTANCE TO NEAREST: SEPTIC TLNK . SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER' <br /> INTENDED USE TYPZ�. OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <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 <br /> r ` , <br /> PUMP INSTALLATION: Contractor �- I"C <br /> Type of Pump F H.P. <br /> { <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP UPAIR. /77 State Work Done <br /> ,DFGTRUCTION 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(TT�jORT of .the well and notify them before putting the well in use. The above <br /> information fl, tr Co the est of my knowledge and belief. <br /> SIGNED - TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> i <br /> FOR DEPARTMENT USE ONLY <br /> i <br /> PHASE I � !� <br /> APPLICATION ACCEPTED BY DATE /14 <br /> �. <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY _ DATE INSPECTION BY DATE/_ - '73 <br /> --CALL FOR A GROUT INSPECTION ,PRIOR TO GROUTING AND FINAL INSPECTION. <br /> xr 1L99 df'K/71iM <br />