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i toze-,— SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO£,;--FFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (.204) x+66-6781 <br /> -"` APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit 130. E <br /> THIS PERMIT EXPIRES 1. YEAR FROM DATE ISSUED Date Issued f p-%2-Z--3 <br /> i (Complete In Triplicate) <br /> sApplication is hereby made to the San Joaquin Local Health Distract for a permit to construct <br /> and/or install. the work herein described. ' This application is made in compliance with San Jaaquit <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local neal.th Distzict.. <br /> JOB ADDRESS/LOCATION _ ,- -a// CENSUS TRACT <br /> Phone <br /> _3 <br /> Owner's Name t <br /> - City ' <br /> . C <br /> ` Address ���»-,-�-- . -. <br /> {{ <br /> Contractor's Name License `p Phone S�' Q7. <br /> TYPE OF WORK (Check) : ~NEW WELL/ / DEEPEN '/ / RECONDITION / / DESTRUCTION /_7 <br /> PUMP INSTALLATION.- / / PLIQ REPAIR / / PUMP REPLACEMENT IL <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK tl..�SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD - CESSPOOL/SEEPAGE PIT OTHER <br /> V INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> - -- <br /> j Industrial Cable .Tool" Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven,; Gauge of Casing <br /> Irrigation Gravels Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> -- Other Other Information <br /> PUMP INSTALLATION: 'Contractor <br /> ' Type of Pump ...� T= .- - - - -R.P. <br /> PUMP REPLACEMENT: /!W State Work Done <br /> PUMP 'tEPAIR: % State Work Done <br /> DF�TRUCTION 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 /> R and the State of California pertaining to or regulating well "construction. Within FIFTEEN DAYS <br /> after completion of my work on a neva well., I will ,_furnish the San Joaquin Local Health District s <br /> r 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 , JTITLE A <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> i M . <br /> r PHASE 1 <br /> APPLICATION ACCEPTED .-BY DATE .CO <br /> " ADDITIONAL COMMENTS: <br /> i PHASE II GROUT INSPECTION PHASE II/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> ' --CALL FOR A-GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> b <br /> E H 1426 5/73IN <br />