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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR O VICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 79 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 73- 3 Li <br /> THIS PERMIT EXPIRES I. YEAR FROM DATE ISSUED' Date Issued 7:�a-73 <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 and the Rules and Regulations of the San Joaquiin Local Health District. <br /> JOB ADDRESS/LOCATION <br /> CENSUS TRACT <br /> Owner's Name Phone / Y <br /> Address <br /> City <br /> Contractor's Name License #/(, . Phone <br /> TYPE'OF•WORK (Check) : NEW WELL DEEPEN /_/ RECONDITION /_7 DESTRUCTION /_7 <br /> AL <br /> PUMP INSTLATION PUMP REPAIR EePUMP REPLACEMENT /_7 <br /> Other / / — <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> -SEWAGE DISPOSAL-FIELD CESSPOOL/SEEPAGE PIT. OTHER <br /> _INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> 4 <br /> Industrial Cable Toole, , 'Dia. of Well Excavation <br /> Domestic/private - Drilled i 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 /> -19 <br /> PUMP REPLACEMENT: / / State Work Done. <br /> PUMP.REPAIR: »--�1;y T'--State-Work-'Done <br /> ESTRUCTION 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 /> SIGNED TITLE <br /> RAW PLOT PLAN ONREVERSE SIDE <br /> PHASE I <br /> FOR DEPARTMENT `USE ..Q.. <br /> NLX <br /> - <br /> APPLICATION ACCEPTED BY /_' DATES ' <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE '- <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL, INSPECTION. <br /> E H 1426 <br /> T/72 1M • <br />