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SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> FOR OFFICE USE: r/ 1601 E. Hazelton Ave.; Stockton, Calif. <br /> Telephone:• (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 13_ foo U1/ <br /> THIS PERMIT EXPIRES 1. ,YEAR FROM DATE ISSUED Date Issued (,'�5�-73 <br /> (Complete In Triplicate) O - /1D0w 2J <br /> Application is hereby made to thetSan 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 /> CENSUS TRACT <br /> JOB ADDRESS/LOCATION , • $~ <br /> rs <br /> Owner's_Name ; Phone d} .]��00- <br /> Address.. <br /> 0Address.. ? City LSeCI t.. -- - - <br /> Contractor's Name License # 2f)&aqq Phone ' <br /> _TYPE OF WORK (Check) : NEW WELL / DEEPEN / / RECONDITION /% DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT /7 <br /> Other / / S <br /> DISTANCE TO NEAREST: SEPTIC TANK ADO* SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELDT CESSPOOL/SEEPAGE PIT — OTHER-- <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation 1bT1q <br /> �[ Domestic/private Drilled Dia, of Well Casing 8 <br /> Domestic/public Driven Gauge of Casing 'a, �T^ <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 Jam+ H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> T <br /> PUMP REPAIR: / / 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 ORT of the well an„d notify them before putting the well in use. The above <br /> information i r to he be o my knowledge and belief. <br /> SIGNED % TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY r 1 DATE ” <br /> ADDITIONAL COMMENTS: z (/ <br /> PHASE II GROUT INSPECTION PHASE L111FINAL INSPECT ON <br /> INSPECTION BY S, DATE INSPECTION BY DATEf-23 <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INS ON. <br /> E H, 1426 4/72 1M <br />