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SAN JOAQUIN LOCAL HEALTH DISTRICT , <br /> FOR OFFICE U E: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �3- <br /> 73_�,3sP <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued .-57 <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. E <br /> JOB ADDRESS/LOCATION Ali Xlkl CENSUS TRACT <br /> Owner's Name r Phone. - 7 <br /> E� <br /> Address L-12L City <br /> Contractor's-Name - __ -r -• - � _ . -- Licensel�� 5. -PhoiteL_ <br /> �- <br /> 60 <br /> TYPE OF WORK (Check): NEW WELL /7r DEEPEN /-7 RECONDITION /-7 DESTRUCTION f7 <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT 4 <br /> w Other /-7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY a <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER UY <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS ,I <br /> Industrial „y Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing 1� ..� <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other _ Other Information <br /> PUMP INSTALLATION: Contractor ,j • <br /> Type of Pump 1 ' Q H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> REPAIR-: h / /.•�"Slatie Work Donee - <br />---PUMP <br /> ,RESTRUCTION OF WELL: Well Diameter Approximate Depth a <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 /> Ej <br /> information is true to the best of my knowledge and belief. <br /> y <br /> SIGNED TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE II <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED ,BY DATE <br /> ADDITIONAL COMMENTS: ' <br /> 4 PHASE II GROUT'. ISP CTIONf` 5 w PHASE INAL INSPECTION 11 <br /> INSPECTION BY ,.a DATE INSPECTION BY DATE 1 <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> 7/72 1M <br /> E H 14261 <br />