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7/eo v 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 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued. j_2-,7_3 <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 S; ��c IIltl/+ A . ' CENSUS TRACT <br /> _ <br /> QP <br /> Owner's Name _ <br /> � ,;�(� -_IT `� - ._ � , , . ,,.. ._ hone ���� 9�� ' <br />.,Address City d) � <br /> i <br /> Contractor`s Name b <br /> VLicense #,?7ic Phone <br /> TYPE OF WORK (Check) : NEW WELL /_7 DEEPEN /_ RECONDITION /7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT / <br /> Other { / :. 4 <br /> 4 <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 SPECIFIGATIONS <br /> Industrial 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 �o <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor ' <br /> Type of Pump _ H.P. f <br /> V&,1.ac> <br /> PUMP REPLACEMENT: /C S tate Work Done , vl, <br /> PUMP--REPAIR; '� - /=/ "State Work Done f <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 isatrue to the best of my knowledge and belief. <br /> SIGNED TITLE j <br /> (DRAW PLOT PLAN ON• REVERSE SIDE <br /> FOR DY TMENT USE ONLY <br /> PHASE I n <br /> APPLICATION ACCEPTED BY _ rQ DATE 7 3 <br /> ADDITIONAL COMMENTS; Y <br /> PHASE II GROUT INSPECTION PHASE II/FIN INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE e;- <br /> CALL <br /> -CALL FOR A GROUT INSPECTION. PRIOR TO GROUTING AND FINAL INSPECTION. G T3 <br /> E H 1426 7/72 1M <br />