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:,� ✓� iia' <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FAR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 73 /�Lriv <br /> _._---- <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued . ,o <br /> rr (Complete In Triplicate) ` <br /> Application is hereby madeito the San Joaquin Local Health District for a ..permit to <br /> P construct <br /> and/or install the work herein described. This application is made in compliance with San Joaqui <br /> County Ordinance No. 1862 and the Rules and Regulations of the San -Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION F' Q 19,4f CENSUS TRACT <br /> Owner°s Name l �+ ��C�/ <br /> - Phone <br /> Address +p / � � G City . <br /> Contractor's Name 4/1 � License �DZd��fp one <br /> TYPE OF WORK (Check): NEW ,WELL / J DEEPS / ,( RECONDITION /_-7 DESTRUCTION _ <br /> PUMP"INSTALLATION / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> i SEWAGE DISPO AL FIELD. CESSPOOL/SEEPAGE PIT OTHER <br /> i <br /> INTENDED USE TYPE OZ WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavatio <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 /> I Other Other Information f 1 <br /> if <br /> PUMP INSTALLATION: Contiactor <br /> Type'of Pump H.P. <br /> PUMP REPLACEMENT: <br /> . / / State Work Done - <br /> PUMP REPAIR: State Work, Done <br /> I <br /> ,DESTRUCTION OF WELL: Well Diameter <br /> Approximate Depth <br /> Describe Material and Procedure <br /> J <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 7y <br /> my knowledge and belief. <br /> 11 <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDEp" <br /> PHASE z FOR MENT USE ONL <br /> APPLICATION ACCEPTED B DATE <br /> PHASE <br /> Q �� <br /> ADDITIONAL COMMENTS: <br /> F PHASE II GROUT INSPECTION PHASE III' FINAL INSPECT <br /> INSPECTION BY DATE INSPECTION BY 3 DATE <br /> E CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPEC ION. <br /> E H 1426 <br /> r 7/72 1M <br />