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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 /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 73-.3.3 8eW <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 7-Lf-" <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 /> JOB ADDRESS/LOCA ION ��� <br /> t� � ���/� CENSUS TRACT <br /> Owner's Name <br /> Phone <br /> Address. 6Y) City <br /> Contractor's Name License 4t-11?00 , Phone <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN /E ONDITION /? DESTRUCTION /-7 <br /> PUMP INSTALLATION / PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANKI 7T-70—SEWER LINES �1 <br /> ., 1�a PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT — OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> _ Industrial a Tool Dia, of Well Excavation C�5 <br /> i omestic/ rivate 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 /> R4 <br /> PUMP INSTALLATION: Contractor n <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / j State Work Done F <br /> i <br /> PUMP REPAIR: / / State Work Done <br /> ESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I` 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 /> I WELL DRILLERS REPORT of the well and notify them before- putting the well in use. The above <br /> informat is a to the best of my knowledge and belief. <br /> a <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHA k AL INSPECTION <br /> INSPECTION BY DATE _ _ INSPECTION BY DATE//— <br /> CALL <br /> ATE —CALL FOR A GROUT INSPECTION .PRIOR TO GROUTING AND FINAL INS Y <br /> E H 1426 <br /> 7/72 1M <br />