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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave.', Stockton, Calif. <br /> Telephone:" (209) 466-6781 <br /> PLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 2-_ q S b <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued �-77/ <br /> (Complete In Triplicate) <br /> .Application is hereby maded o the San Joaquin Local Health District for a permit to construct <br /> and/or install the work in described. This application is made in compliance with San Joaquin . <br /> nu6C <br /> County Ordinance No Z_ i n� the Ru es a Re ulations o e Sa Joaquin Local Health District. <br /> 07 0,4 <br /> J 0 B JDRESS/LOCATION $ CENSUS TRACT �tl� <br /> , <br /> Owners Name Phone <br /> Address City <br /> Contractor's Name License # Z Phone <br /> TYPE-OF-WORK=(Check): ""NEW-WELI ,-DEEPEN -/_/ °"`RECONDITION-/. I"DESTRUCTION-/� <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 "'M <br /> INTENDED USE , TYPE OF WELL CONSTRUCTION SPECIFICATIONS � J <br /> Industrial �.:: Cable. Tool Dia, of Well Excavation. l <br /> Domestic/private „ _.Drilled �, Dia. of Weli Casing � <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary a Type• of Grout I <br /> Other Other Information <br /> .PUMP INSTALLATION; Contractor 4 t <br /> Type of :—Pump., H.P. 22 <br /> 4 <br /> :PUMP REPLACEMENT: � State Work on <br /> PUMP REPAIR: S ate Work one <br /> ;DESTRUCTION OF,,.WELL: We11.Diameter Approximate Depth <br /> - Describe Material and ocedure <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; T 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 ,too the best of my-knowledge and belief. $ <br /> SIGNED AO i TITLE ' <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> .PRASE I Q� <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION I <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION,. <br /> E H 1426 ? 4/72 1M <br />