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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> c9 s F <br /> FOLOFFICE USE: 1.601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> - APPLICATION FOR WELL. CONSTRUCTION OR PUMP PERMIT Permit No. �3� 58G <br /> THIS PERMIT EXPIRES l.YEAR FROM DATE ISSUED Date Issued Z7_ <br /> ?_3 <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 Regulat,lon&of the San oaquin Local: Health District. <br /> j'cP CEN SU S TRACT 05'.3- 0�0.-n7 <br /> JOS AAARESS/LOCA ON Q <br /> Owner's Name Phone ' <br /> City a <br /> Address 6 - <br /> �.. „fi;, ....,. �•:.. �� ,.�. .+..-" hone %t% <br /> Contractor's Name cense ` <br /> T� 4 <br /> TYPE OF WORK Check) :� NEW WELL / / DEEPEN' 'j RECONDITION _ DESTRUCTION <br /> PUMP <br /> .iINSTALLATION PUMP REPAIR'/ PUMP REPLACEMENT /_T <br /> Other <br /> DISTANCE TO NEAREST: . •SEPTIC TAi3K SEWER LINES e PIT PRIVY _ <br /> i SEWAGE DISP L TIELD CESSPOOL/SEEPAGE PIT OTHER Z <br /> CONSTRUCTION SPECIFIC ONS <br /> INTENDED USE TYPE OF WELL <br /> F Industrial ` able Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Dom tic/public ,' Driven Gauge of Casing <br /> rrigation Gravel Pack Depth of Grout Seal <br /> Af <br /> ' Other Rotary Type of Grout <br /> Other Other Information. --- <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. ' <br /> r �PUN(P`REPLACEMENT: ,� �f�/ S- bate;Work-Done <br /> PUMP 'tEPAIR: / / State Work 'Done <br /> ,DFcTRUCTION 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 Distract <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 l and notify them before putting the well in use. The above <br /> information true t the' a of gry knowledge and belief'. <br /> " SIGNED TITLC, . <br /> (D PLOT PLAN ON REVERSE SIDE) <br /> ' FOR DEPARTMENT USE ONLY <br /> PURSE - DATE //�3-73. <br /> APPLIC ' IONJACCEPTED EY <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY RATE S " . <br /> 3 CALL FOR A GROUT INSPECTION-PRIOR TO GROUTING AND FINAL INSPECTION. co <br /> 5Z,731M <br />