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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Call f. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR 'UMP PERM"I"T Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ?_1-_,7_3 <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 Jd-aquir. <br /> County Ordinance No. 1862 and! the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name �_ <br /> Phone <br /> Address a / ��' ]" G� � City S70CII-A,,, / <br /> Contractor's Name4911 P1e .0 0 License # Phone AIVIZ=J ; <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN /_/ RECONDITION /_/ DESTRUCTION /? <br /> ,C(1110ING ' PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> 7. 7°I 9 f�' Other /% -- <br /> DISTANCE TO NEAREST: SEPTIC _TANKSEWER LINES PIT PRIVY <br /> SEWAGE DISPO ALFIELD CESSPOOL/SEEPAGE PI-T- - ,I OTHER <br /> A <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial t Cable Tool Dia. of Well Excavation <br /> Domestic/private t Drilled Dia. of Well Casing (� <br /> Domestic/public Driven Gauge of Casing O <br /> Irrigation 't Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout /}rT <br /> ;t Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: State <br /> Work Done <br /> PUMP REPAIR: / / State Work Done <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 .pextaining 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 i -tr a to t best of my knowledge and belief. <br /> SIGNED <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) + <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY 1N <<^ r V DATE 7 <br /> ADDITIONAL COMMENTS: i <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTIONJ <br /> INSPECTION BY DATE �/�l ��? _ INSPECTION BY DATE ; 2 24. i <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. / <br /> E H 1426 <br /> 7/72 <1M <br /> s <br />