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(� SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOL.O1'IICE USL: /1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 70 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE .ISSUED Date Issued IL,9-73 <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 Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION �.� -7.3 /V _ CENSUS TRACT'' <br /> Owner's Name � ,�►-� -_ (�-i�-�- _ Phone -z <br /> Address 2 73 City <br /> Contractor's Name License #Z'4. t Phone. 4G[s9Sy.?� <br /> TYPE OF WORK (Check): NEW WELL '/? DEEPEN -/ ./ RECONDITION /_/ DESTRUCTION ,/-7 <br /> PUMP INSTALLATION / I PL`MP REPAIR '/ I PUMP REPLACEMENT <br /> Other / I <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY �J <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER V <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable 'Fool Dia. of Well Excavation <br /> X Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public . Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other I Rotary Type of Grout <br /> Other Other Information <br /> PL!MY INSTALLATIONb Contractor <br /> Type "of Pump H.P. / <br /> f PUMP REPLACEMENT: IState Work Done <br /> PUMP `tEPAIR: / / State Work Done <br /> pF'GTRUCTION OF WELL: Well Diameter Approximate Depth . <br /> E Describe Material and Procedure <br />€ I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> C 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 .thelwell and notify them before putting the well in use. The above <br /> information is true to the best of my knowledge and belief. <br /> � a <br /> SIGNED TITLE <br /> (DITAR PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I / <br /> APPLICATION ACCEPTED .BY E r 7� <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION P / AL INSPECTIO <br /> } INSPECTION BY DATE INSPECTION BY <br /> Ej CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSP <br /> P P IL9A 5/731M <br />