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SAN JOAQUIN LOCAL HEALTH DISTRICT " <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone . (209) 466-6781 72-3 <br /> APPLICATION FOR, <br /> WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7L-_2.-3 i-v <br /> THIS PERMIT EXPIRES- 1 YEAR FROM DATE ISSUED <br /> Date Issued �y <br /> In Triplicate) <br /> Application is hereby made to the San JoaquinompleteLocal Health District for a per to <br /> and/or install the work hereance wiconstr..thSan <br /> in described. This application is made in compliuJoaquin <br /> 5 County Ordinance No. 1862 anis the Rules and Regulations of the San Joaquin Local Health District. <br /> Ij JOB ADDRESS/LOCATION <br /> 70 <br /> .f CENSUS TRACT <br /> Owner's Name / . <br /> _j Phone <br /> Address ]0 <br /> •r� City <br /> Contractor's Name -' <br /> License 4f 693 _3Lhone <br /> TYPE OF WORK (Check) : .NEW WELL / DEEPEN /_/ RECONDITION _ <br /> _/� DESTRUCTION 1-7AL <br /> PUMP INSTLATION PUMP REPAIR /—/—PUMP REPLACEMENT <br /> Other f/ / <br /> DISTANCE TO NEAREST: SEPTICTANK - � SEWER LINES <br /> PIT PRIVY <br /> SEWAGE•DISPOSAL FIELD CESSPOOL/SEEPAGE PIT <br /> rcu 5:. .. x OTHER <br /> INTENDED USE TYPE QF WELL <br /> Industrial CONSTRUCTION SPECIFICATIONS <br /> Cable Tool Dia, of Well Excavation <br /> . Domestic/private I Drilled Dia, of Well Casing <br /> Domestic/public ! Driven Gauge of Casing f Qr <br /> Irrigation i Gravel Pack Depth of Grout Seal © P <br /> Other ! Rotary Type of Grout <br /> i Other Other Information r <br /> T w <br /> PUMP INSTALLATION: Contractor , <br /> Type of <br /> Pump <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR. <br /> _ - / / State Work Done � <br /> TRUCTION OF WELL: Well Diameter <br /> Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with gall 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 myo on a new weU, I will furnish the San Joaquin Local Health District a <br /> w <br /> WELL DRILLERS REPORT o thew land tify <br /> before putting the well in use. The above <br /> information is true t the s of d and belief. <br /> SIGNED J� TITLEti <br /> \ f (DRAW PLOT PLAN ON REVERSE SIDE) <br /> PHASE I 1 FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE /O �ADDITIONAL COMMENTS: <br /> PHASE II GROUT �INEStPECTION u raw wa-9 PHASE II <br /> INSPECTION BY DATE p _i-o 6 ,P.�J. /FINAL INSPECTIO <br /> NSPECTHN BYDATE <br /> I2EP= !l /, <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 0// G✓Cl� `las oe [ado :�'f' Y <br /> ?! qel erle' rd p� 7/72 1M <br />