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SAN LOCAL JOA UIN <br /> FOR OFFICE USE: Q HEALTH DISTRICT <br /> 1601 E. Hazelton Ave. , Stockton, Calif. <br /> �. Telephone: (209) 466-6781 <br /> II APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> II <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> 73 <br /> Application is hereby made t.6 the San(Jo Joaquin <br /> (Complete <br /> alrHealthtDistrict fo <br /> and/or install the work herein described, r a permit to construct <br /> This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 an' .the Rules and Regulations of the San Joaquin Local. Health District: <br /> JOB ADDRESS/LOCATION. <br /> CENSUS TRACT <br /> Owner t s Name c. Phone <br /> _� • 9 7 <br /> Address <br /> City ; <br /> Contractor's �amen I� - <br /> License Phone -r <br /> N <br /> TYPE OF WORK ((Check) : NEW WELL /_7 DEEPEN /_7 RECONDITION /_7 DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR /—/ PUMP REPLACEMENT � C} <br /> Other l�/ / -- <br /> DISTANCE TO NEAREST: SEPTICITANK SEWER LINES PIT PRIVY <br /> E <br /> .I SEWAGEDISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER \ <br /> �\ <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial ;IM Cable Tool Dia, of Well Excavation �r <br /> Domestic/privateI Drilled <br /> � Dia. of Well Casing <br /> Domestir�%public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Ik Rotary Type of Grout <br /> Other Other Information <br /> IIIM - <br /> PUMP INSTALLATIION: Contractor i <br /> Type of Pump t <br /> I .P. <br /> PUMP REPLACEMENT: State Work Done �� t <br /> PUMP REPAIR: / / State Work Done <br />.DESTRUCTION OF WELL: Well Diameter <br /> Descrie Material and Procedure Approximate Depth <br /> I hereby agree to comply withj�all laws and regulations of the San Joaquin Local Health District. r <br /> and the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> after completion of my work ori a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the we'll and notify them before putting the 1 in use. The above <br /> information is true to the best of my knowledge and belief. <br /> SIGNED IN k <br /> TITLE <br /> M it (DRAW PLOT PLAN ON REVERSE SIDE <br /> I� <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> � — � <br /> APPLICATION ACCEPTED BY DATE 7 <br /> ADDITIONAL COMMENTS: IM <br /> PHASE II GROUT INSPECTION P E FIN NSPECTION <br /> INSPECTION BY DATE INSPECTION B DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 1 I 7/72 IM <br />