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1 <br /> i <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT ' <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. 5 <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 5`�4 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued _17-7 <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 , CENSUS TRACT 005-170-09 <br /> Owner's Name Phone36k- 3 1 Fj— 1 <br /> Address p© City ,A1� <br /> Contractor's Name � _ ,�,y� 1", .c.� License 4v(p2373 Phonekkrf <br /> TYPE OF WORK (Check) : NEW WELL /�/ DEEPEN /_/ ; RECONDITION /_7 DESTRUCTION <br /> PUMP INSTALLATION /. / PUMP REPAIR " PUMP REPLACEMENT /_7 j <br /> Other /_7 <br /> DISTANCE TO NEAREST: SEPTIC TANK _ ' SEWER LINES PIT PRIVY <br /> . .�.� y .� <br /> _SEWAGE DISPOSAL •FIELD--- - CESSPOOL/SEEPAGE PIT - OTHER fi <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 /> f Domestic/public Driven Gauge of Casing <br /> F Irrigation Gravel Pack Depth, of- Grout Seal - <br /> Other Rotary Type of;#Grout <br /> Other Other Information <br /> PUMP INSTALLATIONS Contractor <br /> _Type-of Pump..-._ _,!-:1 H.P. <br /> PUMP REPLACEMENT: / / State Work Done - 1 <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 best .of my knowledge: and belief. <br /> SIGNET) <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) �^ <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE p� <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE _..INSPECTION BY `T DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION; <br /> E H 1426 7/72 1M , <br />