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_ r <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUPU' PERMIT Permit No. J3 <br /> ;;:y- 1.2 3 /10THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued /S_23 <br /> (Complete In Triplicate) Oe)7-03o-r 9 <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 Ordin nce No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION �-� -7,r ��?<�c '. e� IENSUS TRACT <br /> Owner's Name �� c a �z cam/ Phohe/J <br /> Address ?I ` <br /> � � �� r. � �� J �.I..City <br /> Contractor's Naive � � �,r1r��-� ;/ License #/4 � 373 Phone <br /> TYPE OF,: WORK (Check) : NEW WELL DEEPEN /-7 RECONDITION /-7 DESTRUCTIIDN /-7 --7-F <br /> PUMP INSTALLATION 0 PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PTT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER O <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial X Cable Tool Dia, of Well Excavation � � r <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 /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump .c H.P. <br /> w <br /> PUMP REPLACEMENT: / / State Work Done f <br /> PUMP REPAIR: /% State Work Done MOO <br /> � <br /> jDOESTRUCTION OF WELL: Well Diameter - Appioxiinate 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 Distritt 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 /> ` 4"DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE .3 4`-70 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY _ DATE �-�/ ]3 <br /> CALL ;F'OR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> .E H 1426 7/72 1M <br />