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D.-` <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFI USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7.3 _x 5-1 P <br /> THIS PERMIT EXPIRES 1 YEAR FROMOATS ISSUED Date Issued 5--I 7--73 <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 /> JOE ADDRESS/LOCATION NSUS TRACT <br /> 01 <br /> Owner's NamePhone <br /> Address f Z. Ci <br /> ty <br /> Contractor's Name License # 6p, Phone <br /> &4E�� <br /> TYPE OF WORK (Check) : NEW WELL /_7 DEEPEN�,/ � `RECONDITION Y/_ DESTRUCTION /?� rt <br /> PUMP INSTALLATION / G/ PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other / / — <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY rnrn <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER 14' <br /> INTENDED USE TYPE 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 /> PUMP INSTALLATION: Contractor ,p1 <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done _ -- <br /> ESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> 1 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 TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BYDATE <br /> ADDITIONAL COMMENTS: <br /> PRASE It GROUT INSPECTION PHA I F NAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION .PRIOR TO GROUTING AND FINAL INSPECTI N. <br /> E H 1426 7/72 1M <br />