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l 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. a-L - <br /> THIS- PERMIT EXPIRES '1 YEAR FROM DATE ISSUED Date Issued'g_LLL--73 <br /> t (Complete In Triplicate) <br /> Application is hereby made to the'.San Joaquin Local Health District for a permit to construct t <br /> and/or install the work herein described. This application is made in compliance with San Joaquitl <br /> County Ordinance No. 1862 and' he Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION Z 2 <br /> CENSUS TRACT y <br /> Owner's Name Phone ° <br /> s <br /> Address17 <br /> r� City I� <br /> r <br /> Contractor's Name , <br /> - c License #/ZUIQ Phone <br /> TYPE OF WORK (Check): NEW WELL /—T DEEPEN / / RECONDITION /—T DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC ' ANK SEWER LINES PIT PRIVY <br /> C ,� SWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> ,X, i c Aj <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <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 /> - I <br /> PUMP INSTALLATION: Contractor , r <br /> Type of Pump r - H.P. .--. <br /> PUMP REPLACEMENT: - -f State Work Done <br /> M S J a <br /> r r . <br /> PUMP REPAIR: / / State Work Done * x'` <br /> PESTRUCTION OF WELL: Well-Diameter. ice Approximate Depth <br /> Describe. Material and Procedure <br /> - <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`workj,on a new well, I will furnish the San Joaquin Local Health District a i <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 / T TITLE <br /> RAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY _ ` DATE <br /> ADDITIONAL COMMENTS. <br /> PHASE II GROUT INSPECTION PHASE JIIJFINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION.PRIOR TO GROUTING.AND FINAL INSPECTION. 1 � IE <br /> E H 1426 7/72 1M ? <br />