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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 DELL tbNSTRUCTION OR PUMP PERMIT Permit No. 73-225-U) <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date IssuedS--/7-73 <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 /> JOB ADDRESS/LOCATION / ® ` CENSUS TRACT S �e <br /> Owner's Name <br /> / Phone <br /> Address 6 �~� �y � � (' <br /> City/ dG= p <br /> Contractor's Name License �Phone � �1 <br /> TYPE OF WORK (Check): NEW WELL /DEEPEN /-7 RECONDITION /-7 DESTRUCTION /? <br /> PUMP INSTALLATION L/ PUMP REPAIR /-7 PUMP REPLACEMENT /7 <br /> Other / / _ <br /> DISTANCE TO NEAREST: SEPTIC TANKSEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELDM" <br /> CE SPOOL/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 /> Irrigation <br /> Domestic/public Driven Gauge of Casing 3 <br /> Irrigation __ Gravel Pack Depth of Grout Seal ' <br /> Other Rotary Type of Grout h4 Y ' <br /> Otherp <br /> Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: /7 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 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 <br /> DRAW PLOT PLAN ON TITLE <br /> REVERSE SID <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> .— <br /> siPPLICATION ACCEPTED BY � � DATE ��` "3 <br /> WDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> WSPECTION BY DATE ; INSPECTION BY <br /> ' ^ DATE •�� <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M � <br />