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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 /> r APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> 73r iso F' <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 3 2,'-1-,7_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 Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION L CENSUS TRACT <br /> Owner's Name , / .I r1117&AZZ fsi5llca. . Phone ,262 - 0 LZLI <br /> Address r, City . d=,� <br /> Contractor's Name C f j(/[ License # <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN / / RECONDITION /_7 DESTRUCTION /_ <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 /> t <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICAATIONS <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 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. 41 - <br /> PUMP REPLACEMENT: / / State Work Done X <br /> PUMP REPAIR: — <br /> / / State Work Done <br /> i ,DESTRUCTION 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 /> 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 notify them before putting the well in use. The above <br /> information is true to the best of my knowledge and belief. <br /> SIGNED ta� TITLE /1//�ti <br /> (DRAW PLOT PLAN ON REVERSE .SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PRASE I <br /> APPLICATION ACCEPTED BY DATE I,S"� <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHA , III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE )- �_ <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/7VM <br />