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SAN JOAQUIN LOCAL TIEALTH DISTRICT <br /> FOR.,OFFIGE U5E: 1f E. Hazelton Ave. , Stockton , Calif. <br /> Telephone: (209), 466-6781 <br /> �AP LICATION FOR WELL:-CONSTRUCTION 'OR PUMP PERMIT Permit No. <br /> HIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ; Date Issued <br /> . -.. (Complete in Tkiplicate) <br /> Application is-here <br /> by 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 SanJoaquin Local Health District. <br /> k � � <br /> JOB ADDRESS/LOCATION " CENSUS TRACT` :, D — <br /> -� Phone ' <br /> Owner's Name <br /> City E5C <br /> Address 0 <br /> - License # Phone .?07 <br /> Cos=aAtor's Name <br /> 3 / EPEN '/ / RECONDITION /_7 DESTRUCTION [7 <br /> TYPE OF WORK (Check) : NEW WELL / DE <br /> PUMP INSTALLATION I�I PUMP REPAIR ,/ / PUMP REPLACEMENT <br /> Other /7/ _ <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 SPECIFICATIONS <br /> If Industrial 'Cable Tool Dia. of Well Excavation <br /> Domestic/private _ __.f,' Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of. Casing <br /> 71 <br /> Irrigation Gravel Pack Depth of, Grout Seal <br /> Other Rotary Type of Grout <br /> Other , Other Information" 1 <br /> k <br /> PUMP INSTALLATION: Contractor H.P. <br /> Type of Pump <br /> PUMP REPLACEMENT: /tate Work Done <br /> r PUMP REPAIR: / / State Work Done <br /> ( <br /> PESTRUCTION OF WELL: Well 'Diameter Approximate Depth. <br /> Describe Material and Procedure <br /> � 4 <br /> kI hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> and the State of Californiajpertaining 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 /> z� <br /> �...y n �T TITLE <br /> SIGNED _1 ,� <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY �y <br /> PHASE-1 DATE <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: RASE AL INSPECTIO <br /> PHASE II GROUT INSPECTION EC PATE <br /> INSPECTION BY DATE <br /> --t __ 2 P- ,z_ <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> - 4/72 <br /> E H 1426 <br />