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O SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> OR OFFICE USE; V/ 1601 E. Hazelton Ave. , Stockton, Calif. � 1 (' <br /> Telephone : (204) 466-6781 kr <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT PerJt No. 73- f �q <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued LIZ- 7 <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. 1.02 and the Rule and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/L0TiON I - H ` i , - <br /> US TRACT } <br /> Owner's NameJ1AYL` Phone <br /> Address City <br /> Contractor's Name License <br /> TYPE OF WORK (Check): NEW WELL DEEPEN /_-7 RECONDITION /-7 DESTRUCTION /-7 <br /> PUMP INSTALLATION / / ' PUMP REPAIR /—/.—PUMP REPLACEMENT /-7 <br /> Other L_1 I 91RE RA — — <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 /> Industrial Cable Tool Dia, of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing A 4E <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack. Depth of: Grout Seal <br /> Other Rotary Type of Grout Ai <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H,P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR. / / State Work Done <br /> ASTRUCTION OF WELL: Well Diameter Approximate Depth <br />'* Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulitions.;,of the San Joaquin Local Health Districik <br /> and the State of California pertaining to or reguldting 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 /> SIGNEDCA TITLE _ <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> - FOR DEPART,4ENT USE ONLY - -� <br /> PHASE I <br /> APPLICATION ACCEPTED-BY DATE l - <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTIO PllkmII AL INSPECTION <br /> INSPECTION BY DATE - - 7 INSPECTION_4Y,, 1,, DATE - <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. ~ <br /> E H 1426 7772 IM <br />