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SAN JOAQUIN LOCAL HEALTH DISTRICT l� <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.�3- <br /> 7.5, <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made to the San "Joaquin Local Health District f r 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° th�,/ 7 ba;g I Ie Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION aC��Sd/� / fyl.f Gv- 091viS CENSUS TRACT <br /> r i Ph ' II <br /> Owner's Nam ,� oneI <br /> Address D L . City <br /> Contractor's Name d / <br /> * License # Phone ..7CQ3 <br /> TYPE OF WORK (Check) : NEW WELL % DEEPEN /�/ RECONDITION /-7 DESTRUCTION /- <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 0T'HER r <br />` INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial J. Cable Tool Dia. of Well Excavation <br /> Domestic/private 1 Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other ,i Rotary Type of Grout <br /> ;I Other Other Information "` <br /> PUMP INSTALLATION: Contr jctor I vt- .16A" <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR- / / State Work Done <br /> ,DESTRUCTION 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 DRI REPORT of the well and notify them before putting the well in use. The above <br /> informat on i true to the best of my. knowledge and belief. <br /> SIGNED TITLE <br /> {DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> ` PHASE I <br /> APPLICATION ACCEPTED BY <br /> DATE <br /> ADDITIONAL COMMENTS: G <br /> PHASE II GROUT INSP CTION PRASE III FINAL INSPECTION <br /> INSPECTION BY DATE J/-K- 73 INSPECTION BY La - � <br /> CALL FOR A GROUT .INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />