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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OF ICE U5E: 1601 E. Hazelton Ave. , Stockton, Calif. i <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 73 <br /> �`l-- <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 Joaquinf <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District.. ! <br /> JOB ADDRESS/LOCATION 71 ' <br /> US CENSUS TRACT , . <br /> Owner's Name Phone <br /> Address <br /> City s e 44.E - <br /> Contractor's Name '77D, i<�, _ License # ,2 � oPhone <br /> d7 <br /> 1 <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN /-7 RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR /lam—PUMP REPLACEMENT /_ ' <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 /> IndustrialC <br /> Cable Tool Dia. of Well Excavation n - -43- <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 /> Other 1 ` Other Information <br /> s <br /> PUMP INSTALLATION: Contractor µ <br /> Type of Pump,_, H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: y i 'State. Work Done Id <br /> 1 <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 Distirict <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. s <br /> SIGNED , TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> kPPLICATION ACCEPTED BY DATE J-3Z-2 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION I &NAL INSPECTION <br /> INSPECTION BY DATE INSPE DATE -� <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> 9 H 1426 7/72 1M <br />