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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR PICE 'USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 73-3 ref <br /> 73-3P7Ia <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ? !_?_3 ' <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. 1862 sand the -Rules and Regulations of the San Joaquin Local Health District: <br /> JOB ADDRESS/LOCATION / o� a _ CENSUS TRACT 4 <br /> Owner's Name /L Phone '36 <br /> i <br /> e City <br /> Address C 99 <br /> Contractor's Name L License # Phone 1 ja <br /> TYPE OF WORK (Check) :- -NEW WELLC-/� DEEPEN / / RECONDITION /7 DESTRUCTION / Y� <br /> PUMP INSTALLATIO ' PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> N} <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK �f^ SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial _y_!-:7Cable Tool Dia. of Well Excavation <br /> =---bomestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal ©; <br /> Other Rotary Type of Grout <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 /> - -- __..�..�,�- -��;,.--�.. ..-„ -.r .._� -- �---�l�,,..� •�.-- :.� ��-�.-_,� �,� -...:�._ --: ate..- R� --- <br /> ,DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <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 the best of my knowledge and belief. <br /> G SIGNED <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE-JI FINAL INSPEC ION <br /> , INSPECTION BY DATE Z-2.,D �) INSPECTION BY t +� DATE - <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />