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N 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. ki_0 <br /> F THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ..L_- _ 3 <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 Rulp an Re�ul tons the S Joaquin Local ealth District. <br /> tpENSUS TRACT <br /> JOB AD)RESS/LOCATYON � .r arm 00 <br /> Owner's Name "`�r AA►I'll Phone <br /> � Address '` City <br /> . <br /> Contractor's Name4-64) 0/y License # ����hone 4 -74 <br /> 74 <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN / / RECONDITION DESTRUCTION /rT <br /> PUMP INSTALLATION / / PUMP REPAIR j/ PUMP REPLACEMENT /_7 <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> t SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> . Industrial Cable Tool Dia. of Well Excavation IRS <br /> �k Domestic/private Dfilled; Dia, of Well Casing <br /> Domestic/public Driven' k Gauge of Casing <br /> Irrigation Pack Depth of Grout Sea}. <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 Daned+� f-- <br /> : JDESTRUCTION 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 <br /> and the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> jafter 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 <br /> information is true to the best of kn ledg nd belief. <br /> SIGNED TLE <br /> MAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY r <br /> PHASE I DATE <br /> APPLICATION ACCEPTED BY �t, s�� /(� � ._� <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III INAL INSPECTION <br /> , INSPECTION BY _ DATE INSPECTION BY DATE . ,1 Z <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 -7/72 1M <br />