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Y ; r <br /> • � ,/ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: Y/ <br /> 1601 E. Hazelton Ave. ;-Stockton, Calif. <br /> TelephoneV'.,Q09) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 73-fbi <br /> t � <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date. Issued j 123 <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. 1.862 anis the Rules and 'Regul.ations of the San Joaquin Local Health District. <br /> i <br /> JOB ADDRESS/LOCATION t► / � . CENSUS TRACT <br /> Ff — <br /> - Owner's Name' � a, <br /> /� -- Phone <br /> Address City <br /> Contractor's Name License PhoneS�&19-61 3 <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN /_/ RECONDITION /_7 DESTRUCTION /'7 <br /> r PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT.,, /_7 <br /> 3 <br /> Other, / <br /> ',-.DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOI:/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation 1+ v <br /> ,_ Domestic/private Drilled Dia. of Well Casing p� <br /> . Domestic/public Driven Gauge of Casing <br />.1 Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary <br /> t --- L y Type of Grout <br /> Other Other Information �- <br /> i PUMP INSTALLATION: Contractor <br /> Type of Pump / H.P. <br /> i <br /> PUMP REPLACEMENT: / / State Work Done <br /> T <br /> c:r _ <br /> t <br /> PUI _REPAIR: Y/ _Mate Work_Done <br /> '.RES_TRUCTION 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 tify them before putting the well in use. The above <br /> information is true to the best of myowledge and belief. <br /> . SIGNED } TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE I <br /> FO DEPAR USE ONLY <br /> APPLICATION ACC D BY �. DATE <br /> ADDITIONAL COMMENTS: <br /> P SII ROUT INSPECTION P I AL INSPEC ON <br /> INSPECTION B r DATE �� INSP QNB ATE -`r���� <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M `' � ' <br />