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SAN, JOAQUIN LOCAL HEALTH DISTRICT. <br /> FOR OFFICE USE: 1601 E. Hazelton,.Ave. ,�,Stockton, Calif. <br /> Telephone:,.. (209) 466.'-6781 <br /> s <br /> PLICATION FOR WELL CONSTRUCTION.-,OR PUMP PERMIT Permit No. 72--5z..5 <br /> THIS PERMIT EXPIRES. 1-YEAR'FROM 'DATE 'ISSUED- <br /> Date Issued <br /> (Complete In Triplicate) <br /> Application'is hereb deM.to .the °San �Joaquin Local Health District for a- permit to -construct <br /> and/or install the work- herein described. Thi6-application is.. made in compliance with San' Joaquin <br />. County Ordinance :No-:rrl862. andti,the-.Rules=-•and-,Regtilations of° the San Joaquin Local Health District. <br /> t JOB ADDRESS/LOCATION U v S <br /> �-h S� � CENSUS`TRACT <br /> z <br /> Owner's.Name; <br /> Phone '- - 5104/- 73 2 <br /> Address City e� j <br /> Contractor's Name License # /93 71.rPhone 1-7. <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN '/ / RECONDITION / / DESTRUCTION /_ <br /> PUMP INSTALLATION%/ PUMP REPAIR /% PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY _ <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> 0 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private, Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth .of Grout Seali <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor ; <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done_ <br /> PUMP REPAIR: / / State Work Done <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 <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 mykne led and belief ' <br /> SIGNED - M ..,., TITLE <br /> (Di PLOT'OT` PLAN ON RE RSE SIDE) <br /> OR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II .GROUT INSP TION P INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A-GROUT INSPECTION PRIOR TO GROUTING AND FINAL INS . <br /> E H 1426 <br /> 4/72 1M <br />