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� . SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (204) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 73-19-5-P <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued X6 -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 Joaquin' <br /> County Ordinance No. 1862 and"lthe Rules and Regulations- of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION <br /> ® CENSUS TRACT <br /> Owner's Name �?e�.A,f' Phone � `J' 2303 <br /> — <br /> Address C'�Q � - <br /> r. City r <br /> Contractor's Name ;� ' License #J G .23 2-7 Phone3 4 L124 <br /> _ t <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN /_7 RECONDITION /_7 DESTRUCTION /? <br /> PUMP INSTALLATION / / PUMP REPAIR,/�('/ PUMP REPLACEMENT 17 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES, PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> i <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial A Cable Tool Dia. of:Well Excavation.' <br /> Domestic/private -r Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal- <br /> -Other <br /> ear'Other Rotary Type of Grout <br /> Other Other Information: <br /> PUMP INSTALLATION: Contractor <br /> Type ofi Pump ` .H.P. -(D <br /> F r - - yam, <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: fSCISt <br /> ate Work -Done <br /> DESTRUCTION OF .WELL: Well Diameter - Approximate <br /> Describe Material and Procedure PP Depth <br /> f � <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 . , <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 /> SIGNED <br /> TITLE <br /> (DRAW PLOT PIAN ON REVERSE SIDE <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY - DATE ¢ 3 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT IN9PECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE -(g2_?9r <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />