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I, SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: if 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781-�� n m. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 - rL39jQ <br /> �E THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 3J-_�!_3 <br /> if <br /> 'i (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 wrork, herein described. This application is made in compliance with San Joaquin; <br /> County Ordinance No. 1862 and the AILIes and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION ��" �"�� CENSUS TRACT <br /> Owner«s Naas <br /> Phone <br /> Address �J City <br /> Contractor's Name License # Phone <br /> TYPE OF WORK (Check): NEW WELL /7 DEEPEN /7 RECONDITION DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP `REPAIR PUMP REPLACEMENT /_ <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES s PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE'PIT OTHER <br /> INTENDED USE <br /> II TYPE OF WELL � CONSTRUCTION SPECIFICATIONS � { <br /> Industrial Cable Tool Dia. iof Well Excavation o'y <br /> fDomestic/private i! Drilled Dia. ',of Well Casing <br /> Domestic/public �i Driven Gauge of Casing <br /> Irrigation Gravel Pack- Depth, of Grout Seal x <br />{ Other fi Rotar Type of Grout y <br /> yyI Other <br /> 0ti4rlInformation <br /> PUMP INSTALLATION: Contractor . ' <br /> Type of Pump # H.P. <br /> PUMP REPLACEMENT; _ . /Th /;� State Work Donetu <br /> Y , <br />` PUMP REPAIR: / / State Work Done Y ; <br /> DESTRUCTION OF WELL: Well Diameter i Approximate Depth <br /> -- <br /> Describe Material and Procedure i ' <br /> E �I <br /> I hereby agree to complywithall. 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 /> G after completion: of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of 'Fthe 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 /> � 1 <br /> SIGNED i,!" TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) li <br /> FOR PPPARTIJENT USE ONLY <br /> PHASE I i <br /> APPLICATION ACCEPTED BY ,`. - Al. DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTI N <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 li 7/72 1M <br /> I � <br />