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l+. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT } <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. (� ± <br /> Telephone: (209) 466-6781 l� <br /> PLICATION FOR YELLaCONSTRUCTION OR PUMP PERMIT Permit No., 7z 5?S <br /> THIS ''PERMIT !EXPIRES 1 YEAR FROM DATE ISSUED Date' Issued 2_9 --n, <br /> (Complete Ir,'Triplicate) <br /> Application is Vreby made1to<-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. 1862 'and- the'-"R6les an'd- Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION ��,1. L CENSUS TRACT <br /> Owner's Named n. , Y ► Phone " <br /> .� <br /> Address f. City- <br /> Contractor's <br /> ity .. } <br /> r _ <br /> .. <br /> Contractor's Name License Phone <br /> TYPE OF. WORK (Check) : NEW WELL / / DEEPEN /7 .RECONDITION-/-_5;7­�'=DESTRUCT-ION /-7 <br /> P&P INSTALLATION / / PUMP REPAIR 4/ PUMP REPLACEMENT /_7 <br /> Other <br /> DISTANCE TO NEAREST: "SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER -S <br /> I� w <br /> INTENDED USE it TYPE OF WELL CONSTRUCTION SPECIFICATIONS �b <br /> Industrial k Cable Tool Dia. of Well Excavation <br /> bomestic/private Drilled Dia. -of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation i Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> ' Other Other Information <br /> it <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / 'f/ State Work Done <br /> PUMP REPAIR: _/bT/ State Work Done <br /> iM. <br /> RESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> E <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 REPORT of the well and notify them before putting the well in use. The above <br /> information is true to th6 best. of my knowledge and belief. <br /> SIGNED F TITLE1.Ck. <br /> 1f <br /> (DR4V PLOT PLAN ON REVERSE SIDE) _ <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I (� q <br /> APPLICATION ACCEPTED BY DATE ZS~ <br /> ADDITIONAL COMMENTS: Cii <br /> PHASE II GROITT TRSPECTION PHASE 214/FINAL- INSPECTION <br /> 4 <br /> INSPECTION BY DATE INSPECTION B TE �_ <br /> .p: <br /> CALL.F'OR,A GROUT INSPECTION_PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 IM <br />