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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. Ez=, 5 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> ' (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin L 41 FI lth is 'c for a permit to construct <br /> and/or install the work herein described. Thi i e.0in compliance with San Joaquin , <br /> County Ordinance No. 1$62 and the Rules and Re4ulat s of-th%e §a Joaquin Local Health District. <br /> C7l G Gt �s <br /> JOB ADDRESS/LOCATION r / CENSUS TRACT <br /> Owner's Name Phon <br /> Address T�O �j City <br /> r 7 n <br /> Contractor's Name ansa <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN / RECONDITION /_7 DESTRUCTION /_ <br /> PUMP IN M ATION / / PUMP REPAIR /% PUMP REPLACEMENT 1-7 <br /> Other /_7 <br /> DISTANCE TO NEAREST: SEPTIC TANK ...Z,2n SEWER LINES PIT PRIVY <br /> SEWAGE DISPO FIELD. ��1 CE S OOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF ELL CONSTRUCTION SPECIFICATIONS <br /> Instrial <br /> uCable Tool Dia. of Well Excavation 19 <br /> estic/private Drilled, Dia. of Well Casing. <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal / <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> .DESTRUCTION OF WELL: Well Diameter Approximate Deptli- <br /> Describe Nater al.-and Procedure <br /> c <br /> r- <br /> I hereby agree to comply wit all laws and regulations of the an Joaqui FLocal Heal District <br /> and the State of California0pertaining to or regulating well constructs 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 noy them before putting the well in use. The above <br /> information is t t the b st of owled a and belief. <br /> SIGNED TITLE <br /> DRAW PLOT PLAN REVERSE SIDE <br /> FOR DEPART USE ONLY <br /> PHASE I <br /> APPLICATIO ACCEPTED BY DATE 2-T -72-- <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE /(-/�-�a- <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 4/72 1M <br />