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h <br /> " SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> TOF.:OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ,�' <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued lI_ZU_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 /> 4 <br /> JOB ADDRESS/LOCENSUS TRACT <br /> ADDRESS/LOCATION Y <br /> Owner's Name Oct 11W Phone <br /> _:!�= <br /> Address --5v L City ,/CZ2,e�_ _64v. <br /> r License <br /> / hone <br /> Contractor s Name /�^/��� <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN '/ / RECONDITION / / DESTRUCTION /7 <br /> PUMP INSTALLATION r/ MP PUREPAIR '/ / PUMP REPLACEMENT /-7 <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial M 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 <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done , <br /> PUMP 'tEPAIR: / / State Work Done <br />( ,DFCTRUCTION 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 /> I ;:and the State of California pertaining to or regulating well "construc.tion. Within FIFTEEN DAYS <br /> H.after completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> P ,_ iELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br />,j. "information is true to the best of my knowledge and belief. <br /> SIGNED <br /> TITLE <br /> - <br /> fi <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PI'.ASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE Z <br /> ° CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> �5/73iM <br />