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SAN ,TOA UIN LOCAL HEALTH DISTRICT <br /> STRICT <br /> FOF.:OFFICE UST:: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> . Telephone: (.209) 466-6781 <br /> APPLICATION FOR WELL, CONSTRUCTION OR PUMP PERMIT Permit No, <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued Jz) -.30--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 �l e�w�a erein described. , This application is made in compliance with San Joaquin <br /> ty Ordinance No. 1862 an he Rules and Regulations of the San Joaquin Local 14ealth District. <br /> JOB ADD SS/LOCATION CENSUS TRACT <br /> Owner's Name Phone <br /> Address City <br /> Contractor's Name -� License # Phone <br /> TYPE OF WORK (Check): -N-9W--WELL- /_/ - =DEEPEN-/_/ RECONDITION, /—/ --DESTRUCTION- /-7_ <br /> PUMP INSTALLATION /—/ PUMP REPAIR /—/ PUMP REPLACEMENT p , <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC ThNK SEWER LINES PIT PRIVY 3\1)' <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial , Cable Tool Dia. of'Well Excavation <br /> Domestic/privates Drilled Dia. of. Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> IrrigationGravel Pack Depth of Grout Seal <br /> Other _ Rotary Type of Grout <br /> Other Other Information <br /> t <br /> PUAT INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: State Work Deane 9-19.#w6ar <br /> PUMP UPAIR: /�/ State Work Done <br /> ,DF'zTRUCTION 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 /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTER .BY -1 4DATE/-G2 --' 1 <br /> ADDITIONAL CO:iMENTS: 411) <br /> PRASE II GROUT INSPECTION EThTlaINAL INSPECTION <br /> INSPECTION BY DATE INSPE TOO DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br />\ -- F. w iL,7( r /-v- __ <br />