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"N JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: `; 16�r. Hazelton Ave. , Stockton, Cam. <br /> .} Telephone: {209) 466-6781 <br /> LIGATION FOR WELL CONSTRUCTION OK PUMP PERMIT Permit No. 72---5 6 O <br /> \ .s THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 13.1 Z- <br /> G (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 Joaquii <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> 1416- <br /> JOB ADDRESS/LOCATION d Sip t —at /A1( 8,fv-L-, i4 CENSUS TRACT S�7 <br /> Owner'sName R [ E Phone <br /> Address . City <br /> Contractor's Name License // ?/'40 Phoneden <br /> TYPE OF WORK (Check): NEW WELL/ / DEEPEN /7 RECONDITION f-1 DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR / PUMP REPLACEMENT /7 <br /> Other /—/ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS S <br /> Industrial ble Tool Dia, of Well Excavation O <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout a <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 iL <br /> �� �y��jjy,= <br /> ,DESTRUCTION 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 notify them before putting the well in use. The above <br /> information is true to the best of my knowledge a d belief. <br /> SIGNED -- <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY 4 DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 4/72 1M <br />