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" F �Iv <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> fOL 01�� CE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued -7--5-_71 <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. 1662 and the Rules and Regulations of the San Joaquin Local health District. <br /> JOB ADDRESS/LOCATION f.[> cv /02 CENSUS TRACT <br /> Owner.`S Name Phone <br /> Address City �Y .' <br /> — -- <br /> Contractor's Name License Phone <br /> TYPE}OF WORK (Check) : NEW WELL / DEEPEN/ / RECONDITION /_/ DESTRUCTION /� <br /> PUMP INSTLATION / / PUMP REPAIR / I PUMP REPLACEMENT I�T <br /> Other I I <br /> s — <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES /5"0_ ,PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial <br /> Cable Tool Dia, of Well Excavation l �' <br /> Domestic/private Drilled Aia. of Well Casing <br /> Domestic/public Driven Gauge of Casing S e..7 <br /> T Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> �� .. Other Other Information <br /> f \N <br /> PUMP INSTALLATION: Contractor <br /> Type of'Pump H.P. �. <br /> f <br /> i° <br /> PUMP REPLACEMENT: / / State Work Done `. <br /> PUMP 'REPAIR: State Work Done <br /> DESTRUCTION OF WELL: Well Diameter - ____._ _._ --Appro`xima�--Depth '--� <br /> Describe Material and Procedure <br /> t <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 "constructi.on. Within FIFTEEN DAYS <br /> after completion of my work an a new well, I will furnish the. San Joaquin Local Health District i <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 /> TITLE <br /> SIGNED — <br /> a (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> { PHASE I DATE Z <br /> APPLICATION ACCEPTED .BY <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION—'-----'-'- 'r` _ PHASE III/FINAL INSPECT 0 ?/ <br /> INSPECTION BY DATE INSPECTION BY DATE / <br /> CALL FOR A. GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 �731M - <br />