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I <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: <br /> 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone t• .(,209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. If <br /> 73 � <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> �SZZ �• OR69~ (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 and the Rules and Regulations of the 'San Joaquin Local Health District. <br /> JOB ADDRESS/LOCAT ON &*eSUS TRACT <br /> Owner's Nacre �, Phone <br /> Address Cl <br /> - CAd4G� _ �,,. City <br /> Coritxactor's Name <br /> i <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN /_7 RECONDITION /� DESTRUCTIONS - } <br /> PUMP IN5 ALLATION / / PUMP REPAIR / / PUMP REPLACEME /7 <br /> Other <br /> t <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LII�ES PIT PRIVY w'• 5 j <br /> SEWAGE DISPOS FIELD.-j,� CESSPOOL/SEEPAGE PIT OTHER ! <br /> INTENDED USE TYPE OF WELLw CONSTRUCTION `SPECIFICATI NS f 4- <br /> Industrial Cable Tool' " Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven "" , Gauge of Casing 00 <br /> TT <br /> Irrigation travel Pack - Depth of Grout Seal ., <br /> Other Rotary Type_jof Grout <br /> 0 - 0tiiI T iff f r I} <br /> f - <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. s <br /> PUMP REPLACEMENT: _ / / State—Work Done <br /> PUMP REPAIR: / / Stat;---,Work Done - of 0. <br />,DESTRUCTION OF WELL: Well Diameter- _ j _ _ Approximate Depth_A;�s <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�i <br /> - <br /> WELL DRILLERS REPORT o the well and otify Them"-. efore-putting the .weli in use: n e- above <br /> information is true o he best a kno ledge and belief. �, <br /> SIGNED'.---. - - - _�._. `TITLE- <br /> {DRAW PL LAN- ON REVERSE -SIDE <br /> FO EPARTMENT USE ONLY <br /> PRASE I <br /> APPLICATION A EPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PRASEJI aMUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE/_. 3 INSPECTION- BY DATE ' - 17 3 <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 -� IM ; 3 <br />