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SAN JOAQUIN LOCAL HEALTH DISTRICTd <br /> OFFICE USE: <br /> 1601 E. Hazelton Ave. , Stockton, Calif. <br /> FOR <br /> Telephone: (209) 466-6781 5 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit 130. <br /> THIS PERMIT EXPIRES" I YEAR FROM DATE ISSUED Date Issued 7 3 <br /> (Complete In Triplicate) <br /> n HealthApplication is hereby made to the Sanbedaqu <br /> and/or install the work herein, ThasOcal applicationDrict istra permit tconstruct <br /> made incamp1iancewith San Joaquin <br /> County_ Ordinance, No. 1862 and the Rules and Regulations of the S� J��(i� calr Health District. <br /> `f`f©= k? ";0' 3 °: _x � � ENSUS TRACT _ <br /> JOB ADDRESSJLUCATION <br /> f �rgyy u _ . Phone <br /> Owner's Name <br /> ` <br /> City <br /> Address • <br /> License 21rphone le <br /> Contractor's Name <br /> STRUCTION /_7 <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN / J RECONDITION /PEREPLACEMEN— 1-7 <br /> PUMP INSTALLATION J J PUMP REPAIR LyIUMP <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> - CONSTRUCTION SPECIFICATIONS <br /> ' ©L <br /> INTENDED USE TYPE OF WELL <br /> Industrial Cable Tool Dia. of Well Excavation <br /> E Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> _ Irrigation Gravel Pack Depth of Grout Seal <br /> y� <br /> Other <br /> Rotary Type of Grout <br /> Other _ Other Information <br /> Contractor ,, d�e ; <br /> PUMP INSTALLATION H.P. ZO <br /> Type of Pump <br /> PUMP REPLACEMENT: /�C/ Skate "Wok Done <br /> k t <br /> PUMP REPAIR: / 1 State .WQrk Done <br /> r Approximate Depth <br /> .DESTRUCTION OF WELL: Well Diameter <br /> Describe .Mater ial 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 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 know d e--an belief <br /> ITLE <br /> SIGNED LO PLAN ON R RSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I; <br /> DATE i <br /> APPLICATION ACCEPTED BY `��T <br /> ADDITIONAL COMMENTS.: p NAL INSPECTION <br /> PHASE II GROUT INSPECTION' IN <br /> INSPECTION BY _ INSPECTION BY DATE <br /> DATE - <br /> CALL FOR A, GROUT INSPECTION PRIOR TO GROUTING AND ,FINAL INS C 7/72 IM <br /> E H 1426 <br />