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SAN JOAQUIN LOCAI. 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. 73-40 41 <br /> 7.3-3,13 P <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued b IT 73 <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> and/or install the work herein 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 Air/LOCATION =E S =:7�' Z LZ 3 t? CENSUS TRACT <br /> Owner's Name Phone <br /> Address 1`e4e City <br /> Contractor's Name Ak&v Y �✓ icense I) hone <br /> V� � _31 <br /> TYPE OF WORK (Check) : NEW WELL 'Xj DEEPEN /_/ RECONDITION /—T DESTRUCTION /—T <br /> PUMP INSTALLATION FUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other / / T <br /> DISTANCE TO NEAREST: SEPTIC TANK SE R LINES V PIT PRIVY <br /> OV <br /> SEWAGE DISPOSAL FIELD 8*&&PA0E/SEEPAGE PIT Z"Q -OTHER <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 /> XIrrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor 1_< S <br /> Type of Pump ,`,fes H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> ,DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material 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 knowledge and belief. <br /> SIGNED TITLE <br /> RAW PLOT PLAN ON REVERSE SID <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I /"�7 APPLICATION ACCEPTED BY(�l <br /> DATE to ` <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY /'!J. DATE INSPECTION BY DATE ;0-_j`7.3 <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />