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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton. Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 73 7 yOO <br /> . APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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. 1$62 and .the Rules and. Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION ?� CENSUS TRACT <br /> Ji�/1� <br /> Owner's Name .. �� d mac. Phone' <br /> -Z-3 i�Z-7�o <br /> Address — t City f--=- ► �� <br /> Contractor's Name m T License, #g $Al03 Phone <br /> TYPE OF WORK (Check) : NEW WELL / EEPEN / / RECONDITION /-T DESTRUCTION /7T ,. <br /> PUMP INSTALLATION /ZL::� REPAIR / / PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES-74,5-d� PIT PRIVY 1�f <br /> SEWAGE DISPOSAL FIELD,,4 CESSPOOL/SEEPAGE PIT OTHER vv <br /> J <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS oar <br /> Industrial Cable Tool Dia. of Well Excavation zo <br /> //domestic/private Drilled Dia. of Well Casing <br /> t Domesticipublic Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal C3 Other Rotary!✓' Rotary Type of Grout e d rv-fm Ivc, <br /> Other Other InformationQ <br /> PUMP INSTALLATION: Contractor € <br /> r <br /> Type of F m , H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> ,DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure I <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 /> infor tion is true to thMbeif myknowledge and belief. <br /> SIGNED ' TITLE t V <br /> - (DRAW PLOT PLAN ON REVERSE SIDE) <br /> F R DEP NT USE ONLY <br /> PHASE <br /> ITIIJ V" <br /> APPLICATION ACCE ED BY DATE y " <br /> ADDITIONAL COMMENTS: <br /> PHASE I GROUT INSPECT ON P INAL INSPECTION . <br /> INSPECTION B DATE INSPECTIO BY DATE <br /> i CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSF.ECTION. <br /> E H 1426 _ 4/72 1M L� <br />