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t y <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE 'i :E: % 1601 E. Hazelton Ave. , Stockton, Calif, <br /> i Telephone: (209) '466-6781 <br /> M APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.�_ y y� <br /> F THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued/C-2 <br /> j (Complete In Triplicate) <br /> Applicationiiis hereby madd',to the San Joaquin Local Health District for a permit to construct <br /> and/or install the work herein described. This application is trade in compliance with San Joaqui <br /> County Ordinance No, 1852 aird the Rules ,and Regulations of the San Joaquin Local Health District. <br /> 't <br /> .TOB ADDRESS/LOCATION az, CENSUS TRACT S`J� <br /> Owner's Name, ko e ° Phone <br /> Address . <br /> city <br /> Goatractor'sName License % Phone - <br /> k. j - <br /> TYPE OF WORK (Check): NEW WELL /-7 DEEPEN / RECONDITION /� DESTRUCTION /-7 <br /> PUMPIINSTALLATION / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other / <br /> c yyt,r e _ <br /> ilt <br /> a DISTANCE-TO 'NEARES ' SEPTIC' ANK SEWER LI S PIT PRIVY <br /> t� WAGE DISPOSAL FIELD CES POOL/SEEPAGE PIT OTHER <br /> INTEND TY60E OF WEL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing W <br /> Domestic/public Driven Gauge of Casing .� <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout Cj <br /> Other Other Information <br /> 4 <br /> PUMP INSTALLATION. Contractorr <br /> ` . :�TYpe� of Pump H.P. 3 <br /> } 3 / <br /> PUMP REPLACE NT: <br /> / / �� State Work Done <br /> z <br /> PUMP REPAIR: / State Work Done <br /> ESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure W--_-_ <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 DRILLERSIREPORT of the well and notify them before putting the well in use. The above <br /> information is true to the b' t of my knowledge and belief. <br /> SIGNED , J <br /> TITLE uy <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> ,. FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE /b-f2 <br /> ADDITIONAL COMMENTS: <br /> "z <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY, DATE INSPECTION BY --- — DATE/0 -2--y-,72 <br /> CALL FOR A`GROUT INSPECTION PRIOR.TO GROUTING AND FINAL INSPECTION. _ <br /> E H 1426 7/72 1M <br />