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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephones (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 73- 35-14J <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date:'! Issued <br /> (Complete In Triplicate) <br /> f <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 Regulations of the San Joaquin Local Health District. <br /> y <br /> JOB ADDRESS/LOCATION CENSUS TRACT t <br /> Owner's Name p; Phone <br /> Address City . <br /> Contractora Name d , -- License �� hone ,,,,,,..�� ��'''j� <br /> �'.;q3 <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN /_7 RECONDITION /_7 DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR / PUMP REPLACEME T <br /> n �7/ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of-Well- Excavation " l <br /> Domestic/private Drilled Dia. of Well Casing fJ`1 <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal L5 o <br /> Other Type of Grout <br /> Other Other Information <br /> PUMP -INSTALLATION". Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT- / / State Work Done ZO- <br /> PUMP REPAIR, /,:/ State..Work Done - j <br /> k <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 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 C TITLE <br /> - -- -- <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I r � O <br /> APPLICATION ACCEPTED=BY DATE '.�—4) <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION VrIAO II F AL INSPECTION <br /> INSPECTION BY DATE '/ -',�" INSPECTION DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUPING AND FINAL INSPECTION. �J <br /> • H 1426 7/72 1M �j <br />