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/A 5 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT � <br /> FOR OIFVIC USE: a <br /> l6Ol E. Hazelton Ave. , Stockton, Calif. . <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ,2_ / 4 <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) 270. <br /> Application is hereby made to the San Joaquin Loral Health District for a permit to con truct <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 /> JOBADDRESS/LbZATION <br /> // C' /- f K L/4/v,C CENSUS TRACT <br /> Owner's Name Phone <br /> 3 6 % �c._ Sf 7_ <br /> Address <br /> �� �m— Cit <br /> y 74ut-ao <br /> Contractor's Name _ 1 Is., License #1 Phone <br /> TYPE OF WORK (Check) : NEW WELL /_7 DEEPEN /_7 RECONDITION /_7 DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD • CESSPOOL/SEEPAGE PIT- - OTHER <br /> INTENDED USE TYPE OF WELL <br /> 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 �-i <br /> t ' <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor 'L ( <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: + <br /> State Work Done <br /> i <br /> PUMP REPAIR: State Work Done <br /> DESTRUCTION OF WELL: Well Diameter -�-=Approximate Depth i <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 /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR D' TMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PRASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE / - <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> � <br /> E H 1426 -- 7/72 1M h .� <br />