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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1501 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No, _7 <br /> THIS PERMIT EXPIRES i YEAR FROM DATE ISSUED Date Issued 713 <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. 18 2 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION r CENSUS TRACT <br /> Owner's Name Z Phone <br /> Address`; City SGI��1 kJ <br /> Contractor's Name , License 1b2;7!P6)/0 Phone ,;2�d7 <br /> TYPE OF�WORK (Check) : NEW WELL / /. DEEPEN /_/ RECONDITION /_7 DESTRUCTION /_ <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> c Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> i <br /> INTENDED USE- TY-PE ,OF WELL . CONSTRUCTION SPECIFICATIONS <br /> Industrial ' ' Cab le; Too l' 6.:, 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 I <br /> Other Other Information 1 <br /> PUMP INSTALLATION: Contractor �{ <br /> Type of Pump, H.P. <br /> l <br /> PUMP REPLACEMENTState Work Donez&e <br /> PUMP 'REPAIRa - G/ / 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 weir 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 SIDE4e2��� <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I / <br /> APPLICATION ACCEPTED BY DATE �/6�� <br /> ADDITIONAL COMMENTS:. <br /> PHASE II PPUT INSPECTION POW I NAL INSPEC N <br /> INSPECTION BY DATE INSPE N DATE <br /> + r <br /> za <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING -AND" FINAL INSPECTION. <br /> E H 1426 7/72 -_ 1M <br />