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SAN JOAQUIN LOCAL HEALTH DISTRICT AA `11 {0 <br /> FOR OFFICEYUSE: <br /> 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUME PERMIT Permit No. 73 _ L1:7 <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 Ruler a Vetations of the San Joaquin Local Health District. <br /> JOBift/LOCATION CENSUS TRACT f <br /> Owner's Name , 1 . Phone <br /> Address <br /> --E� Citx-� l� � <br /> Contractor's Name �' �iS , <br /> License ��. phone E f —72 -;'V i <br /> TYPE`OF WORK (Check) : NEW WELL X DEEPER /-7'-"RECONDITION /_j DESTRUCTION <br /> PUMP INSTZLATION / / PUMP REPAIR / / PUMP REPLACEMENT /-7 }� <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK f SEWER.LINES 7-PIT PRIVY <br /> SEWAGE DISPOSAL FIELD Ul" CESSPOOL/SEEPAGE PIT` OTHER /Z/ <br /> t <br /> 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 0 <br /> /public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout . r � ' <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor Morrll /?s, <br /> Type of Pump :s H.P., <br /> PUMP REPLACEMENT: / J State Work Done <br /> PUMP REPAIR: / State Work Done <br /> pESTRUCTION 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 I <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 t <br /> information is tru to the best of my knowledge and belief. i <br /> SIGNED ' TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) �( <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE Q '� 3 f <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT IN PECTION PHA II/FINAL INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY DATE Q <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECT ON. W <br /> E H 1426 7/72 1M ! <br />