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e ✓ T JOAQUIN LOCAL HEALTH DISTRIC' <br /> FOR OFFICE USE: 16dYE. Hazelton Ave. , Stockton, Ca1*1T. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No,73_ /440 4� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued .// -e2-73 <br /> (Complete In Triplicate) <br /> 1pplication is hereby made to the San Joaquin Local Health District for a permit to construct <br /> ind/or install the work herein described. This application is made in compliance with San Joaqui <br /> .ounty Ordinance No. 1862 and* the Rules And Regulations of the San Joaquin Local Health District. <br /> �,'�r <br /> JOB ADDRESS/LOCATION cr is /p/lam C k CENSUS TRACT <br /> haner's Name !- �/�• q 111-0t1''y1l Phone �����.� <br /> L <br /> lddress xd pJ / City <br /> :ontractor's Name '�//2�` c0 �C License "Phone <br /> 'YPE OF WORK (Check) : NEW WELL /DEEPEN /_/ RECONDITION /-7 DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS e <br /> _ Industrial Cable Tool Dia. of Well Excavation <br /> _ Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation H Gravel Pack Depth of Grout Sealf'c> <br /> Othei Rotary Type of Grout fir. <br /> Other Other Information 2. � •' - <br /> 'UMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> 'UMP REPLACEMENT: / / State Work Done <br /> 'UMP REPAIR: / / State Work Done <br /> )ESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> ind 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 /> 4ELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> information is true to the best of my knowledge and belief. <br /> �r <br /> SIGNED TITLE <br /> fir' (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> 'RASE I <br /> \PPLICATION ACCEPTED BY DATE <br /> WDITI0NAL COMMENTS: / <br /> PHASE I G I S C PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPE ION BYE DATE Z/ <br /> CALL FOR A GROUT INSPEC ION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />