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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. 7.5--.2e,7Zs.j <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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 Regula ions of the San Joaquin Local Health District. <br /> JOB ADDRE53W4 qP CATIONEf 12 CENSUS TRACT <br /> l <br /> Owner's Name Phone <br /> Address City e 6 <br /> Contractor's Name License #;L_, a Phone,?5 �� �'•�/ <br /> TYPE OF WORK (Check) : NEW WELL / D-EEPEN /_/ RECONDITION /_7 DESTRUCTION <br /> PUMP INSTALLATION REPAIR / PUMP REPLACEMENT /7 , <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANKZK�,fSEWER LI ES ,--- PIT PRIVY <br /> SEWAGE DISPOSAL FIELD/Q p. ,f SSP00L/SEEPAGE PIT�,�-,�_ OTHER ---� <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation C <br /> --fro-mestic/private Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout <br /> Other Mary Type of Grout �j <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor L <br /> Type of P H.P. <br /> PUMP REPLACEMENT: / / State Woo Done <br /> FUI- ° REPAIR: / / State Work Donee <br /> t <br />,I)ES_TRUCTION 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 i7istrict a <br /> WELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> info ation is true t est my knowledge and belief. <br /> F E <br /> SIGNED ~' TITLE _ yam_ <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> ` FOR DEPARTMENT USE ONLY <br /> FHAS <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III aINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> B H 1426 7/72 -1M <br />