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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F <br /> 1100. OFFIC USE: 1601 E. Hazelton 'Ave. , Stockton, Calif. <br /> - + , <br /> Telephone: ' (209) 466--6781 73-/70 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 113-112P <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED , Date Issued �-/b 73- <br /> v 3 (Complete In Triplicate) r <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 /> 70B ADDRESS/LOCATIONy / � y CENSUS TRACT <br /> Owner's Name ' �� Phone '—Z6 �(S� <br /> Address <br /> k City ',�/ E <br /> Contractor's Name /�/ /� `��U� <br /> i Licensedo7y,sPhone 5GG-t�6Z� <br /> TYPE OF WORK (Check): NEW WELL DEEPEN / / -RECONDITION. /7 <br /> _DESTRUCTION /?� <br /> PUMP +INSTALLATION 0�`Pi3MP REPAIR '/ / PUMP REPLACEMENT /- <br /> Other ./ / <br /> r DISTANCE TO NEAREST: SEPTIC 'TANK /420 / SEWER SEWER LINES PIT PRIVY f v1 ! <br /> SEWAGEIDISPOSAL FIELD CESSPOOL/SEEPAGE PIT iOTHER f' <br /> INTENDED USE TYPE OF WELL .� <br /> CONSTRUCTION SPECIFICATIONS � <br /> Industrial I Cable Tool Dia, of Well Excavation <br /> Domestic/private ! Drilled Dia. of Well Casing <br /> Domestic/public 1 Driven Gauge of Casing 2 <br /> Irrigation ` f. Gravel Pack. Depth of Grout Seal <br /> i Other Rotary Type of Grout <br /> e Other Other Information 1 ,' <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> H <br /> r <br /> .P. _e�- <br /> 1 = N <br /> PUMP REPLACEMENT: , ¢ <br /> State Work Done <br /> ' PUMP REPAIR: State Work Done 3i <br />`- .DESTRUCTION`OF"WELL:"—Well=Diameter - - Approximate-Depth--- <br /> DescribeMaterial 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 FIFTEEk 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 the well and notify them before putting the well in use. . The above <br /> information is cru to the best my kn edge and belief. <br /> SIGNED - TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> PRASE I <br /> FOR DEPARTMENT USE ONLY <br /> - <br /> APPLICATION ACCEPTED BY . DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY , DATE _ _ �-�� n . INSPECTION BY ATE 3- 77 <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 4/72 1M f* <br />