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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: /'1, 1603. E. Hazelton-Ave. , Stockton, Calif. fl�-3 <br /> Telephone: (209) 466-6781 - � <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No 73-,30 U) <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate)' + <br /> Application is hereby ma,le to the San Joaquin Local Health District for a permit to construct <br /> and/or install the work herean 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/LOCATION4 Al - CENSUS TRACT <br /> ISI <br /> Owner's Name aY .p Phoned l <br /> Address 1109,4 G. _ City <br /> Contractor' s Name /f X 311 —,, License # !$e13'® Phone -� <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN%_7_ RECONDITION /_7 DESTRUCTION /7 <br /> PUMP INSTALLATION PUMP REPAIR /—/7-PUMP REPLACEMENT /_ <br /> Other <br /> � k <br /> DISTANCE TO NEAREST: SEPTIC TANK � SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER b <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial i Cable Tool Dia. of Well Excavation jam" <br /> K Domestic/private _ Drilled Dia. of Well Casing' <br /> Domestic./public Driven Gauge of Casing sem- <br /> Irrigation Gravel Pack Depth of Grout Seal 6"0' <br /> Other i' Rotary Type of Grout <br /> ll' Other Other Informations <br /> JNIti <br /> PUMP INSTALLATION: Cont ractor •�G =�-��� �� '$�. 5" kl <br /> Trype of Pump _ H.P. <br /> IE� <br /> PUMP REPLACEMENT: /, / State- Work-Done <br /> I PUMP REPAIR: State Work Do <br /> + <br /> ESTRUCTION- OF-WELL: - Well,Diameter. - Approximate Depth _ <br /> Describe Material and Procedure <br /> I hereby agree to compl}� with all laws and regulations of th San Joaquin Local Health District j <br /> and the State of California pertaining to or regulating well construction'. Within FIFTEEN DAYS <br /> after completion of my ,4ork on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of!i1the 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 TITLE ,- --- <br /> aE (DRAW PL PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY !/� - DATE 6 �f� <br /> ADDITIONAL COMMENTS: - <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY dj; DATE INSPECTION BY DATE <br /> a CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> 7172 1M <br /> E H 1426 �� - <br />