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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: `1601 E. Hazelton Ave. , Stockton, Calif. <br /> v Telephone: (209) 466-6781 73-172- <br /> 3`�Z p <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued*-12 73 <br /> (Complete In Triplicate) <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 /> JOB ADDRESS/LOCATION C CENSUS TRACT <br /> Owner's Name <br /> ..� <br /> /V 'j,/�'j,Il FI�d Phone <br /> Address S City 6,SC <br /> Contractor's Name License <br /> _7?Oj OPhone &3R7, p7 <br /> TYPE OF WORK (Check) : NEW WELL /_7 DEEPEN / / RECONDITION /7 DESTRUCTION /`7 i <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT IL-T--- <br /> Other <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 <br /> Domestic/private Drilled Dia. of Well Casing A <br /> Domestic/public Driven Gauge of Casing v! <br /> Irrigation Gravel Pack Depth of Grout Seal, ti <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. f <br /> PUMP REPLACEMENT,.' /State Work Done /}tr(./` ---.., �� .v, <br /> PUMP- REPAIR-.-._ "` / State-Wank Done <br /> JDESTRUCTION 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 ;E <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 /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY - <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL, COMMENTS: <br /> PHASE II GROUT INSPECTION PRAW I NAL INSPECTION <br /> INSPECTION BY DATE INSPECTI BY DATE <br /> R: <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />