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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. <br /> THIS PERMIT EXPIRES 1 YEAR FROM.DATE ISSUED Date Issued 3 7 3 <br /> (Complete In Triplicate) Z6 <br /> QI?-loo- <br /> Application is hereby5made to; the San Joaquin Local Health District for a permit 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 /> JOB ADDRESS/LOCATIgN <br /> CENSUS TRACT S 6 <br /> Owner t s Name Phone 9- <br /> Address <br /> City <br /> Contractor's Name ' <br /> Licensy ���Phone,� <br /> - m <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN / / ; RECONDITION•-/77 -DESTRUCTION <br /> PUMP INSTALLATION / / PUMP�REPAIR 0/ PUMP REPLACEMENT /_ <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY '0 <br /> SEWAGE DISPOSAV FIELD CESSPOOL/SEEPAGE PIT OTHER <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 Gaugeiof Casing <br /> irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of_Grout <br /> Other, . ` Other.Iiiformation - <br /> L <br /> PUMP INSTALLATION. Contractor <br /> Type of Pump r i H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIRa State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> it <br /> I hereby agree to comply.with all Yaws 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 /> JELL DRILLERS REPORT of the' well and notify them before putting the well in use. The above <br /> Lnformation is true to the best of my -knowledge and belief. <br /> f <br /> SIGNED \\V <br /> TITLE <br /> (DRAW, PLOT PLAN ON�IREVERSE SIDE �a�. <br /> \FOR DEPARTMENT USE ONLY <br />?HASE I <br /> OPLICATION ACCEPTED BYDATE z <br /> ADDITIONAL COMMENTS: - - <br /> PHASE II GROUT INSPECTION; PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE %,11,3 <br /> CALL FOR A GROUT .INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />