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+ �z. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> VOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephones '(209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. &= 570r,l() <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED bate Issued/ _7 . <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 ADDRESS/LOCATION (p CENSUS TRACT <br /> Owner' Name Phone <br /> Address City <br /> Contractor's Naa, License # � PhoneZQW40_C"__� <br /> d"� 1 <br /> TYPE OF WORK (Check) : NEWI'(,�LL�7 DEEPEN /% RECONDITION /_7 DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /_` <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK A SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD .- - -CESSPOOL/SEEPAGE PIT 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 /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other . Rotary Type of Grout <br /> .,f 10ther Other Information <br /> w_z <br /> PUMP INSTALLATION: Contractor ' <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ' <br /> /i / State Woo rk Done <br /> PUMP REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter lof \W-Ji"3`/ly Appr imate Depth <br /> Describe Material, and Procedure <br /> I hereby agree to comply Oith all lawsy and regulations of(Che 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-wel-i;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 rue to the st of ,my�knowledge and belief, <br /> r <br /> SIGNED ' _,x 4... ' TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE ©_ " <br /> ADDITIONAL COMMENTS: <br /> PHASE II GLRQUTIINSPECTION P S I FINAL INSPECTION <br /> INSPECTION BY TE INSPECTION BY DATE <br /> r <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPE ON. <br /> E H 1426 7/72 1M <br />