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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.73��a6 <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED Date Issued 5_x-73 <br /> (Complete In Triplicate) 2-2-5'-02®-v <br /> Application is hereby made to the Sax: 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 /> 73�f1 -9: Esc a�vB -- <br /> 'JOB ADDRESS AOCATION CENSUS TRACT �. <br /> Owner's Name Phone --7L� <br /> Address r City <br /> Contractor's Name License_# I„2o� Phone ti? <br /> TYPE OF WORK (Check): NEW WELL �� DEEPEN /� RECONDITION /? DESTRUCTION — <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /� W + <br /> 411 <br /> Other / / -� � <br /> DISTANCE TO NEAREST: SEPTIC TANK - SEWER LINES PIT PRIVY h <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> 4 <br />! INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial - Cable Tool Dia. of Well Excavation <br /> y. Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal _Q -- �( <br /> Other RotaryType of Grout <br /> Other Other Information <br /> l K <br /> PUMP INSTALLATION: Contractor <br /> _ Type of Pump „ H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> FPUMP`REPAIR:" 1-7—State Work Done <br />{ ,DESTRUCTION OF WELL: Well Diameter tjApproximate Depth Z <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and r gulations, of the an aquin ocal 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 /> FORD ARTMENT USE ONLY <br /> PHASE I 7 <br /> APPLICATION ACCEP D BY DATE ' / Z/ <br /> 1 <br /> ADDITIONAL CO <br /> P IT INSPECTION II NAL .INSPECTION <br /> INSPECTION B DATE INSPE IQN B DATE �-Z( -7 <br /> CALL FOR A GROUT INSPECTION-PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7172 1M <br />