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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> fFOR OF CE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> LE .1( Telephone.: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> _5, <br /> THIS PERMIT EXPIRES 'l YEAR FROM DATE ISSUED <br /> In Date Issued 22=_,-7-2-3Application is hereby made to the San ( eTriplicate) <br /> Joaquin Local Health District for apermit^ <br /> and/or install the work herein described. This application is made in compliancetwithnSanuJoaquin <br /> County Ordinance No. 1862 anti the Rules-and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION <br />` CENSUS TRACT <br /> f Owners Name <br /> Address 5��// Phone _ 0 <br /> City <br /> Contractor's Name <br /> License # <br /> D r Phone <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN / / RECONDITION /� DESTRUCTION _ { <br /> r PUMP INSTALLATION <br /> /�/ PUMP REPAIR / / PUMP REPLACEMENT/? � <br /> Other 1/7 <br /> , <br /> 1 ; <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER LINES PIT PRIVY � � <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT <br /> OTHER , <br /> INTENDED USE TYPE OF WELL L} f <br /> IndustrialCONSTRUCTION SPECIFICATIONS <br /> !X Cable Tool Dia, of Well Excavation <br /> Domestic/private i Drilled Dia, of Well Casing -, �, <br /> Domestic/public I Driven Gauge of Casing <br /> X _ Irrigation Gravel Pack <br /> Other Depth of Grout Seal <br /> Rotary Type of Grout d <br /> Other Other Information <br /> PUMP INSTALLATION: ContraItor j <br /> Type of! Pump H.P. <br /> PUMP REPLACEMENT: — <br /> State Work Done <br /> PUMP REPAIR: } <br /> State Work Done <br /> ESTRUCTION OF WELL: Well Diameter <br /> r` 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, <br /> WELL DRILLERS REPORT of the well and notify I will furnish the San Joaquin Local Health District a <br /> them before putting the well in use. The above <br /> information is true to the best of my knowledge and belief. <br /> SIGNED M <br /> TITLE 'E <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED $���Y I - <br /> UDDITIONAL COMMENTS: �� - DATE <br /> ft .i v <br /> PHASE II GROUT INSPECTIO HASE...kIII/FINAL INSPECTION <br />[NSPECTION BY DATE INSPECTION BYr <br /> DATE�g- 7-�� <br /> CALL FOR A GROUT INSPECTION PRIOR-TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M, <br />