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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FUR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209)466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 71,--f3.;�10 <br /> THIS PERMIT EXPIRES l YEAR FROM DATE IS <br /> . SUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health b istrict 'for a permit to construct <br /> and/or install the work herein described. Thisapplication` is made in compliance with San Joaquin <br /> County Ordinance,No. 1862 and the Rules and 'Regulations of theme-San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION ® �� ' d 2'3 T0d�0-2,6 <br /> CENSUS TRACT <br /> Owner's Name. <br /> Phone <br /> Address A <br /> D - City <br /> �r <br /> Contractor's Name Of , i Licensei II/ .lY 6�Phone,727;�f r <br /> F TYPE,OF`+-WORK (Check): NEW`WELL /-7 DEEPEN /7 RECONDITION /-7 DESTRUCTION /-7 w <br /> i PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT. /? <br /> DISTANCE ,TO' NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> Y t" <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER ;p <br /> INTENDED USE . TYPE OF WELL` k CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool. Dial. of Well Excavation I <br /> Domestic/private - Drilled <br /> Domestic Dia. of Well Casing <br /> /public Driven Gauge of Casing <br /> Irrigation.. jGravel Pack" Depth of Grout Seal <br /> Other{ Rotary , Type of Grout <br /> ,.Other. �.Y Other Information e� <br /> 1 f444� <br />'-'PUMP INSTALLATION: Contractor .`mp � <br /> Type of Pu <br /> _ H.P. , <br /> PUMP REPLACEMENT:_ / / State Work`Done <br /> PUMP REPAIR:_ ; St te,.Work Done {F 1! <br /> ,DESTRUCTION OF WELL: Well Diameter <br /> (il Approximate Depth <br /> DescrIbe' Material and Procedu e <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 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 i <br /> information is true to_ the best of my knowledge and belief. \ <br /> r <br /> SIGNED � TITL <br /> RAW PLOT PLAN ON REVERSE S <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY ,. DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II OUT INSPECTION PHASE III FINAL INSPECTION, <br /> INSPECTION BY DATE INSPECTION BY (EH DATE <br /> CALL FOR A GROUT_INSPECTION PRIOR To GROUTI AND FINAL INSPECTION. <br /> E H 1426 Mr le;r,�,�A 7/72 1M / <br />