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0, <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USg: 11601 E. Hazelton' Ave. , Stockton, Calif. <br /> 1 Telephone: (209) ,466-6781 1 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7.3�`f�w <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUSD Date Issued S 3/ ? <br /> {{ (Complete in Triplicate) <br /> Application is hereby made tlo the Saiz Joaquin Local Health District fpr a permit to construct <br /> and/or install the work herein described. This application is made incompliance with 'San Joaquin <br /> County Ord��in-�anc/��e N!o. 862�an'd' the R les and Regulations of the San Joaquin Local Health District. <br /> L_O'f 0 5 � �1 ' /1 I L� � <br /> JOB ADDRESS/LOCATIONY' '-' t I -� _ <br /> CENSUS TRACT <br /> 4 Owner's Name - ' - <br /> Phone <br /> Address City <br /> Contractor's Name License Phon <br /> TYPE OF WORK (Check): NEW WELL DEEPEN /-7 RECONDITION` /-7 DESTRUCTION /`7 <br /> PUMP INSTALLATION / / PUMP REPAIR /—/ PUMP REPLACEMENT /-7 <br /> Other / / -- <br /> DISTANCE TO NEAREST: SEPTICETANK SEWER LINES PIT PRIVY <br /> i <br /> SEWAGE DISPOS FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> Q <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> _ Industrial . Cable Tool Dia, of Well Excavation <br /> N ; <br /> Domestic/private i 1,-Drilled Dia. of Well Casing <br /> _ Domestic/public I Driven Gauge of Casing 9- <br /> Irrigation . I Gravel, Pack Depth of Grout Seal <br /> Other <br /> _-Rotary Type of GroutC4 4 E44 <br /> 3, . <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> .DESTRUCTION OF WELL: Well Diameter 4 _.. . i- .� - Y —� - <br /> -• 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 ertaining 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 notify them before putting the well in use. The above <br /> information is true to the best of my knowledge and belief. <br /> SIGNED J y <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> F DE MENT USE ONLY <br /> PHASE I <br /> APPLICATION EP BY DATE <br /> ADDITIONAL CO <br /> E I GROUT INSPECTI N P II AL INSPECTIO <br /> INSPECTIO DATE - INSPE ATE - Z- <br /> CALL FOR A GROUT INSPECTION, PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M i <br />