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SAN JOAQUIN "'LOCAL HEALTH DISTRICT ' (L4 <br /> FOR OF' ICE USE: 1601 E. Hazelton Ave . , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR YELL- CONSTRUCTION OR PUMP PERMIT Permit No.73-L(aK w <br /> THIS PERMIT'EXPIRES 1 YEAR FROM DATE ISSUED Date 'Issued �S- �.a-7 3 <br /> (Complete In Triplicate) ' 017- <br /> Application is hereby made-tolthe -Sati 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 Reg ations of.—the"" Local: Health District. <br /> 17 <br /> the <br /> JOB ADDRESS/LOCA ON : -S'47; <br /> 7 { NSUS TRACT <br /> _ <br /> Owner's Name phone <br /> Address CCity-1. <br /> ' - J <br /> Contractor's.Name - " License !la? Zz ,�hone . y� � <br /> TYPE OF WORK (Check): NEW WELL / / DEEPEN / RECONDITION / DESTRUCTION /_ <br /> PUMP INSTALLATION / / UMP REPAIR / / UMP REPLACEMENT /_ <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PTT PRIVY <br /> SEWAGE DISPOSSAL FIELD C SSPOOL/SEEPAGE PIT OTHER <br /> Y, <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS ' <br /> Industrial Cable Tool Dia. of Well Excavation <br /> iv - <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 <br /> Type of Pump H.P. �( <br /> PUMP REPLACEMENT, /_77 State Work Done ' <br /> PUMP REPAIR: / J 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 d notify them before putting the we^ in use. The above <br /> information is rue to the be m knowledge and belief, <br /> SIGNED TITLE <br /> (DRA T PLAN ON REVERSE SIDE <br /> OR DEPARTMENT USE ONLY <br /> PHASE I p <br /> APPLICATION ACCEPTED BY DATE d <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE_ III/FINAL INSPECTION <br /> INSPECTION By . DATE ;>j INSPECTION BY _ (rte , ` DATE 7-7if <br /> CALL FOR A GROUT INSPECTION PRIOR:.TO GROUTING AND FINAL INSPECTION, <br /> E H 1426 7/72 1M <br />