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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. 7� 3/yo <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ,2 7 73 <br /> (Complete In Triplicate) <br /> Application is hereby made -to the San Joaquin Local Health District for -a permit to construct r <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 f0 CENSUS TRACT S h s <br /> Owner's Name Phone jp / <br /> Address f <br /> City. [{ � <br /> Contractor's Name Licens i _ -�,�Phone �-S/Ca <br /> 6 _ ts�9 - <br /> TYPE OF WORK (Check): NEW WELL /7 DEEPEN /7 RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION /0'PUMP REPAIR / / PUMP REPLACEMENT /_ <br /> Other / / — <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER W <br /> V <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 Gauge of Casing <br /> k <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 REPLACEMM: � <br /> /k--T State Work Done <br />,' PUMP REPAIR: J / State Work Done <br /> ESTRUCTION OF WELL: Well Diameter <br /> 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 k <br /> information is true to the best of my knowledge and belief. <br /> F J'% <br />, SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE i <br /> APPLICATION ACCEPTED BY �_.. DATE <br /> ADDITIONAL COMMENTS __ <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE ,E <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. I <br /> E H 1426 7/72 1M <br />