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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. y <br /> Telephone; (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUT1P PERMIT Permit <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued'6--1" -73 <br /> (Complete In Triplicate) ` <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct <br /> and/or install the work herein described. This applications is made in compliance with San Joaquini <br /> County Ordinance No. 1862 and the Rules and Regulations of the Sari Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 0/ c?7 -CENSUS TRACT <br /> Owner's Name ��� 1 <br /> Phone I <br /> Address t,{ /V Z <br /> Contractor's Name . -uy `?�.t <br /> 4 License 4{ Gs":r 6r Phone 4,iggggea <br /> TYPE OF WORK (Check) : NEW WELL J% DEEPEN /_% CO DITION /—[ DESTRUCTION /_7 ! <br /> PUMP INSTALLATION / / P RE AIR Zy—PUMP —REPLACEMENT /7 <br /> Other / / — <br /> � t <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWS LIN 5 PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER b <br /> INTENDED USE TYPE OF WEL CONSTRUCTION SPECIFICATIONS <br /> --� Cable oo Dia. of Well Excavation <br /> Domestic/private Dril Dia. of Well Casing <br /> Dbmestic/public Driv n Gauge of Casing <br /> Irrigation Grav k Depth of Grout Seal <br /> Other R ar Type of Grout <br /> r Other Information { <br /> 1 <br /> PUMP INSTALLATION., Con a for <br /> Type Pum <br /> H.P. <br /> PUMP REPLACEMENT: <br /> / State ork Done <br /> PUMP REPAIR: <br /> State ork Done <br />_DESTRUCTION OF WELL: Well ame er <br /> Describe terial and Procedure Approximate Depth <br /> ,f <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 rYz7it ._Gz ,� L TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> R DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: DATE 6 <br /> PHASE II GROUT INSPECTION PHASE 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 <br /> 7/72 1M <br />