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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR. PUMP PERMIT Permit No. 73-/33 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) 90 �( - o70 -o / <br /> Application is hereby made til 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 Joagc <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District <br /> 1`� J CENSUS TRACT <br /> -JOB ADDRESS/LOCATYON <br /> Owner's Name <br /> Address 7/ . ' �I 4 ` City <br /> Contractor's Name d� <br /> %lt>'o License !I�7( /n Phone Z t <br /> IL <br /> TYPE OF WORK (Check) : NEW WELL %/ DEEPEN /-7 RECONDITION /-7 DESTRUCTION / <br /> PUMP INSTALLATION / / - PUMP REPAIR / /, PUMP EPLACE/MENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD . CESSPOOL/ EEPAGEPIT OTHER » _ .�• <br /> ..t- <br /> -z �' t� dam-`/ FrL•P / •�� lair ,.a`/� �: 7��-/- - -r-�- � <br /> INTENDED USE PE OF ELL _ Z CONSTRU ION SPECIFICATIONS <br /> Industrial <br /> Cable Tool Dia. of Well Excavation <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 '1 - Rotary - Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor 4 <br /> Type of Pump L - z. ' i H.P. <br /> PUMP REPLACEMENT: / / State Work Done �</�A <br /> PUMP REPAIR: / / State Work Done <br /> L <br /> DESTRUCTION OF WELL: Well Diameter Approximate 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 Distric <br /> and the State of California pertaining to or regulating well construction. WithinFIFTEENDA) <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health Distric <br /> WELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> information i true to thelbe t of my knowledge and belief. - <br /> SIGNED ' 'i TITLE <br /> ( w PLOT PLAN ON REVERSE SIDE) <br /> II FOR DEPARTMENT USE ONLY <br /> PHASE I ! /)_ ' DATE <br /> APPLICATION ACCEPTED BY !!!! l <br /> ADDITIONAL COMMENTS: PHASE II /FINAL INSPE TION <br /> PHASE II GROUT INSPECTION DATE <br /> INSPECTION BY ? DATE - INSPECTION BY <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING FINAL INSPECTION 4/72 IM <br /> F. H 1426 <br />