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SAN JOAQUIN LOCAL HEALTH DISTRICT } � <br /> f • �© r <br /> FOR OFFICE USE: Y 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466 .6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued /. -3-7�. <br /> (Complete In Triplicate) 92Y 4090 -OV <br /> Application''is hereby�mad��to the San Joaquin Local Health Distract for a permit to construct <br /> and/or tiohinstall 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 strict. <br /> Health Dii <br /> ��'��—. r�'o co /�r� �lj� Itsl CENSUS TRACT <br /> JOB ADDRESS/LOCATION / f <br /> Owner's Name ' <br /> Phone <br /> Address �.�.�;L� .�� City <br /> Contractor's Name . 2�1 <br /> License # Phone N <br /> rt <br /> V) <br /> TYPE OF WORK (Check): NEW WELL /�/ DEEPEN / J RECONDITION /-7 DESTRUCTION % Z <br /> PUMP INSTALLATION / PUMP REPAIR '/ / PUMP REPLACEMENT <br /> Other / / <br /> x <br /> DISTANCE TO 'NEAREST: SEPTIC TANK _ SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL <br /> CONSTRUCTION SPECIFICATIONS <br /> Industrial. Cable Tool Dia. of Well Excavation., <br /> Domestic/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 /> tt other other Information <br /> 47 <br /> +w- <br /> PUMP INSTALLATION: Contractor `j� � s�� <br /> Type of Pump H.P. d <br /> n <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 <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 beist of my knowledge and belief. <br /> TITLE <br /> SIGNED <br /> . � <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FO EP T' T USE ONLY <br /> PHASE I � <br /> k APPLICATION ACCEP BY DATE -2,3--.73 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION II / NAL N <br /> INSPECTION BY DATE INSPE ON DATE <br /> PECTIO <br /> .117 CALL FOR A �REU�.INSPECTION PRIOR TO, GROUTING AND FINAL INSPECTION. 4/72 IM <br /> E H 1426 <br />