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rSAN .JOAQUIN LOCAs, HEALTH DISTRICT <br /> FQR OFFICE.USE• 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. � /d <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 1 3-73 <br /> C41 I f' rT ^ `� (Complete In Triplicate) -,41J /k-7- a( /Z <br /> Application is hereby mafi6_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 /> JOS ADDRESS/LOCATION X j_ p AAM G CENSUS TRACT <br /> Owner's Name n3f, Phone rf <br /> Address . / , ' <br /> City <br /> Contractor's Na Na License # Phone <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN / / RECONDITION /? DESTRUCTION /_7 <br /> AL <br /> PUMP INSTLATION REPAIR /X/ PUMP REPLACEMENT /_7 <br /> Other J% -- <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL1 <br />_ � CONSTRUCTION SPECIFICATIONS <br /> Industria <br /> l. .�_A._. Cable. Tool • Dia. o -Well Excavation:- <br /> Domestic/private Drilled Dia, of Well Casing ;r <br /> Domestic/public ;Driven ,Gauge of Casing <br /> fX Irrigation Gravel Pack ' Depth of Grout Seal <br /> Ln <br /> Other Rotary Type of Grout <br /> .Other Other Information �^ <br /> PUMP INSTALLATION: Contractor ,>' <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ` <br /> State Work Done <br /> PUMP REPAIR: / / State Work Done g2z2VC <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 i <br /> after completion of my work on a new well, I will furnish the San .Joaquin Local Health District a <br /> 4ELL 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, know ge_and belief. <br />;IGNED a <br /> ITLE <br /> ( W PLOfi PLAN ON ERSE SIDE-- �� <br />'RASE I OR DEPARTMENT USE ONLY <br />►PPLICATION ACCEPTED BYI , DATE <br /> IDDITIONAL COMMENTS: _ <br /> PHASE II GROUT INSPECTION PHAS i FI AL INSPECTION <br />:N5PECTION BYDATE INSPECTION BY DATE <br /> CALL FOR AJ GROUT INSPECTION PRIOR TO-GROUTING AND FINAL INSPECT <br /> E H 1426 7/72 , 1M <br />