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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> Fr—.Or. OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br />' APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.;�73_ 5-3 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued /0-/6 -7 3 <br /> i (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 t San Joaquin Local health District. <br /> JOB AJ}DR SSgfO T10 `g� a CENSUS TRACT <br /> Owner's Name Phone <br /> Address / �` 0 Cg 1 '� �' ' ' C� --- = - - City ! <br /> Contractor's Name p License �, one�7 <br /> TYPE OF WORK (Check) : NEW WELL /� DEPEN '/_/ RECONDITION / / DESTRUCTION <br /> AL / - I <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 CONSTRUCTION SPECIFICATIONS <br /> Industrial able Tool Dia. of Well Excavation l <br /> omestic/private Drilled Dia. of Well Casing /;X!_ - <br /> Dom tic/public Driven Gauge of Casing p g g / b <br /> rrigation Gravel Pack Depth of Grout Seal S Z1 <br /> Other Rotary Type of Grout c, (T <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> Ik PUMP REPLACEMENT:NT: StateWork Done <br /> PUMP 'PAIR: / / State Work Done _ _ - <br />� i <br /> DFRTRUCTION 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 />'i SIGNEDTITLE --- <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> d Pn&SE I <br /> APPLICATION ACCEPTED BY ���,��, / —_ _ -- DATE /O , 2173 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE16 ",� " 7.3 INSPECTION BY DATE �6 <br /> CALL FOR A GROUT .INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E,H_1426 . : - 5/.731M` , <br />