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T <br /> / SAN JOAQUIN LOCAL, HEALTH DISTRICT <br /> FOR OFFICE USE: II11// x,601 E. Haxelton. Ave:, Stockton, Calif. <br /> Telephone: - (209) 466--6781 <br /> APPLICATION FOR4WELV CONSTRUCTION OR PUMP PERMIT Permit No. 7J-3�U kJ <br /> THIS PERMIT EXPIRES 1-:YEAR FROM DATE ISSUED . Date Issued_ <br /> e ` (Complete In Triplicate) t7 D 3-t dv 4_3" <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- Re.gulations of the, San Jo uin Local lHealih 'District. <br /> E;L -O4.� <br /> JOB ADDRESS/LOCATION ( ZZ CENSUS TRACT g, G <br /> Owner's Name :,:�O,B !�'. EV� <br /> Phone <br /> Address . City..-- A <br /> Contractor's Name LL License ta.Zzj�96hone p � <br /> -- - W <br /> TYPE OF WORK (Check): NEW WELL _LII DEEPEN /_7 RECONDITION /_7 DESTRUCTION / 7 <br /> PUMP INSTTION / / PUMP REPAIR / / PUMP REPLACEMENT /� y1 <br /> Other — <br /> DISTANCE TO NEAREST: SEPTIC TANK WER LINES PIT PRIVY <br /> SEWAGE DISPO FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial able Tool Dia. of Well Excavation <br /> :::i�_ Omestic/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 /> i <br /> PUMP INSTALLATION: Contractor ¢ <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 i <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 Wtrue to the be of my knowledge and belief. <br /> SIGNED TITLE C <br /> (D LOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY ! <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE IT GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE ,� INSPECTION BY d DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />