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Hf SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (204) 466-6781 . <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 1,1- 'SoLt {� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued.-X` ..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 Joaquin Local Health District. <br /> JO ADDRESS/LOCATI ONorr , 7��, �,cJ, ,�i�d( ESS� TRACT <br /> Owner t s Name Phone 1 , 'D <br /> Address ]O C,, -Q��� I` Cit �/.<—��� <br /> } y <br /> 4`J <br /> Contractor's Name �',.r.c� <br /> License 4� %_3 Phone26 - <br /> TYPE OF WORK (Check) : NEW WELL /_7 DEEPEN /_% RECONDITION /_7 DESTRUCTION /7 _k <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT /7 fN <br /> Other / / -� <br /> C7 < <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> LF 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 Seal <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor .� P �s <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / State Work Done A,- <br /> U <br /> ��� <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 my knowledge and belief. <br /> SIGNED �L�c' v" �'-'�'i� TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> / 17/7 <br /> APPLICATION ACCEPTED BY _ DATE Z <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS III FINAL INSPECTION f <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />