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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. p 3 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued j ,7 73 <br /> (Complete In Triplicate) .V,? - 150 ?� <br /> Application is hereby made to the San Joaquin Local Health District for a permit toconstruct <br /> and/or install the work herein described. This application is made in compliance with San Joaqui <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin, Local Health District. <br /> JOB ADDRESS/LOCATION r <br /> CENSUS TRACT ,5 <br /> Owner's Name Phone <br /> Address � { -City <br /> rt Contractor's Name Liceris'b # Phone <br /> TYPE OF WORK (Check): NEW WELL /'% DEEPEN /_/ RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION /LUMP REPAIR / / PUMP REPLACEMENT /? <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANKEWER_LI�TES�PIT PRIVY <br /> SEWAGE DISPOSAL lip- <br /> FIELD ((�SSPOOL/SEEPAGE PITS OTHER .� <br /> INTENDED USE TYPE OF WELL r CONSTRUCTION SPECIFICATIONS m <br /> _- + Industrial i Cable Tool -Dia. of Well Excavation <br /> t— I�mestic/private Drilled Dia. of Well Casing 5' <br /> t Domestic/public Driven <br /> y , f,...= Gauge of Casing <br /> Irrigation; Gravel Pack #' Depth of Grout Se 1 <br /> Others 4o­ntary �. Type of Grout <br /> Other -Other Information <br /> PUMP-INSTALLATIOi Contractor <br /> ''' lb•. <br /> Type of ? �. H.P. --� • <br /> PUMP REPLACEMENT: / / State Work Done I '- <br /> PUMP-REPAIR: / / State Work Done' <br /> .7ESTRUCTION OF WELL: Well Diameter I Approximate-Depth <br /> Describe Material°-and-Procediii76"' , <br /> I hereby agree to comply with all lawstand 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` Distriet 8` <br /> WELL DRILLERS REPORT of the -weld and notify'�th m lefore putting the well in -use. The above l <br /> infor tion is true to the o y k wle�dge andfhelief. L <br /> ' <br /> SIGNED ' TITLE rIle <br /> DItA PLOT P REVERSE SIDE) <br /> P,. FOR DEPARTMENT USE ONLY <br /> P SE I <br /> APPL CEPTED BY ' r DATE <br /> I ADDITIONAL COMMENTS: <br /> PHAS& II GROUT INSPECTION <br /> ME.-z <br /> INAL INSPECTION <br /> INSPECTION BY I DATE / - INSPECT DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />