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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFAPE USE: VV 1601 E. Hazelton Ave. ,, Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> j APPLICATION FOR WELL CONSTRUCTION OR P'U'MP PERMIT Permit No. <br /> t <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued, j-_- --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 Joaqui <br /> County Ordinance No. 1862 and the Rules and Regulations of =the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 0 QA CENSUS TRACT <br /> Owner's Name Phone <br /> Address pp City � <br /> f Contractor's Name License # Phone '75 3X <br /> f•„TYPE�OF:WORK-(Check). �w NEW:WELL -/=/" DEEPEN / / ' RECONDITIONS'/''" DESTRUCTIQN /�'�'_ '`'"'�`� <br /> PUMP INSTALLATION /—/ PUMP REPAIR / PUMP REPLACEMENT . /? <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES. PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER to <br /> ` C <br /> INTENDED° USE = TYPE OF WELL 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 F Gravel Pack Depth of Grout Seal <br /> Other ! Rotary Type of Grout <br /> Other Other Information <br /> yvi <br /> i Lam" C�tr <br /> PUMP INSTALLATION: Contractor <br /> i Type of Pump — �1 - - �A '' .�/ H.P. <br /> ;• PUMP•REPLACEMENT: / / State Work Done O AU,9J� <br /> f PUMP REPAIR: / / > State Work Done <br /> ,AESTRUCTION WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> `t <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 thelwell 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 /> / I (DRAW PLOT PLAN ON REVERSE SIDE) f <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE /P- .1 <br /> ADDITIONAL COMMENTS: �' �,, <br /> PHASE jROUT.IINSPECTZON PUSII INSPECTION <br /> INSPECTION BY {DATE INSPECTION BY � r ',DATE <br /> CALL FOR A GROU INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 y s- 7/72 1M <br />