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SAN JOAQU�, HEALTH DISTRICT �?W .} <br /> 1 ! Stockton, Calif. <br /> FOR OFFICE USE: 1641 E.Telephone: <br /> (209 466-6781 <br /> !i' Telephone: ( ) PERMIT Permit NO- /27 -/�'9 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP 7� <br /> it THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Date Issued <br /> (Complete In Triplicate) permit to construct <br /> ed. This application is made in compxocale with SDistrictan ih <br /> A licati'on is hereby made to the 5a ibJoaquin Laval Health District for a P L <br /> PP <br /> and/or install the worki,herein desR ulatians of the San Joaqu n <br /> County Ordinance No. 1862 and 'the Rules and Reg CENSUS TRACT <br /> JOB ADDRESS/LOCATION phone <br /> Owner's Name City <br /> Addressj 37 <br /> 7 License # �W Phone <br /> Contractor's Name _ J <br /> RECONDITION DESTRUCTION I�T <br /> TYPE OF WORK (Check) : 11 NEW WELL /_7 DEEPEN REPAIR <br /> I PUMP REPLACE NT I� <br /> IPUMp INSTALLATION / PUMP REPAIR /{/ <br /> f i Other / / <br /> SEWER LINES PIT PRIVY <br /> DISTANCE TO NEAREST: ',SEPTIC TANK _ CESSPOOL PIT OTHER <br /> SEWAGE DISPOSAL FIELD r <br /> CONSTRUCTION SPECIFICATIONS --S <br /> NTENDED USE !I TYPE OF WELL <br /> Cable Tool Dia. of Well Excavation <br /> _ Industrial !I' Drilled Dia. of Well Casing >� <br /> Domestic/private Driven Gauge of Casing <br /> Domestic/public.! . <br /> Irrigation '' , Gravel Pack Depth of Grout Seal ' <br /> Rotary Type of Grout <br /> Other - Other Information <br /> Other <br /> ------------- <br /> PUMP NSTALLATION, �� Contractor H.P. <br /> Type of -Pump _ h <br /> G •- <br /> PUMP it <br /> EPLACEMENT- / / State Work Done <br /> _ --- <br /> PUMP �tEPAIR: <br /> !r / / State Work Done <br /> Approximate Depth <br /> F J)ESTRi1CTI0N OF WELL:iiameter <br /> i Well Describe Material. and Procedure <br /> F ., <br /> I hereby agree to comply with all laws and regulatioin of the <br /> construction.San Joaquin LoWithinaFIFTEENtDAYS <br /> and the State of California pertaining to of Wiliulfurnish the San Joaquin Local Health District <br /> afte completion of 'my work on a new well, <br /> WELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> information is trueto the best of my knowledge and belief. <br /> TITLE <br /> SIGN D DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> ASE I �� DATE <br /> 'L'. :CATION ACCEPTED BY <br /> [ IONAL COMMENTSPHASE III/FIN AL INSPECTION <br /> PHASE II GROUT INSPECTION INSPECTION BY DATE <br /> 'CTION BY cb, . DATE <br /> FOR A GROUT INSPECTION PRIOR TO GROUTING�AND"FINAL INSPECTION. 7/72 1M <br /> ' 1426 <br />