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FOR OFFICE USE: f� SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.7 -273 P <br /> THIS PERMIT EXPIRES 1 YEAR FROM BATE ISSUED Date Issued 3017-3 <br /> Application is hereby made to the San (Joaquin eIn Local Triplicate) <br /> htDistrict for a permit to cons <br /> and/or install the work herein described. This application is made in compliance with nSan uctJoaquin <br /> County Ordinance No. 1862 and the Rules and R ulations of the San Joaquin Local Health District. <br /> } <br /> JOB ADDRESS/LOCATION <br /> j CENSUS TRACT <br /> Owner's Name _ <br /> Phone <br /> Address <br /> City <br /> Contractor's Name <br /> License # Phone I <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN /% RECONDITION /_7 D 5TR <br /> PUMP INSTALLATION UCTIONN /_ <br /> PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other- �/ / �" <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> gr <br /> SEWER LINES P PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT <br /> OTHER <br /> INTENDED USE TYPE OF WELL $r <br /> IndustrialCONSTRUCTION SPECIFICATIONS <br /> Domestic/private <br /> Cable Tool Dia. of Well Excavation <br /> � <br /> Drilled Dia. of Well Casing <br /> Domestic/public Driven �• <br /> Irrigation Gauge of Casing <br /> Depth of Grout Seal <br /> Other Gravel Pack D <br /> Rotary Type of Grout <br /> € Other Other Information <br /> 1 - <br /> PUMP INSTALLATION., Contractor <br /> Type of Pump _ H.P. _ <br /> / / State Work Done <br /> PUMP REPLACEMENT: , <br /> PUMP REPAIR: ,State Work Done <br /> RESTRUCTION OF WELL: Well- Diameter <br /> Describe Material and Procedure Approximate Depth <br /> I hereby agree to comply with all laws and regulationsof 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 onia 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 /> yIGNED � , <br /> TITLE <br /> + `(DRAW PLOT PLAN ON REVERSE SIDE <br />'RASE I FOR DEPARTMENT USE ONLY <br />►PPLICATION ACCEPTED BY <br />►DDITIONAL COMMENTS: <br />;NSPECTION BY BATE <br /> �. - <br /> PHASE II GROUT INSPECTION PHASE II FIN INSPECTION <br /> DATE INSPEC ION BY <br /> _0 D E (, 2 <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECT N. <br /> E H 1426 <br /> 7/72 1M <br />