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N JOAQUIN LOCAL HEALTH DISTRIC'.,wo <br /> OR OFFICE USE: l 160wE. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ,�1 e) <br /> 7y_ /-2-7P <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued .?y�741 <br /> (Complete In Triplicate) <br /> plication 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 /> ounty Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> .1B ADDRESS/EG`E�ON U' CENSUS TRACT <br /> ner's Name Phone <br /> adress ��� e City <br /> i <br /> —ntractor's Name ��� lj/f� l , ��i7S License �;�,�/ Phone� � <br /> PE OF WORK (Check) : NEW WELL / DEEPEN /_/ RECONDITION /_/ DESTRUCTION /_ _ <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT <br /> Other / / <br /> STANCE TO NEAREST: SEPTIC TANK SEWER LINESPIT PRIVY <br /> .. SEWAGE DISPOSAL FIELDAjdQj. CESSPOOL/SEEPAGE PIT64 {- OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> — Industrial Cable Tool Dia. of Well Excavation /�'� <br /> y Domestic/private _,� Drilled Dia. of Well Casing lv^, <br /> Domestic/public _ Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> rTMP INSTALLATION: Contractor <br /> Type of Pump 4 'Z Z H.P. <br /> LIMP REPLACEMENT: / / State Work Done <br /> %P REPAIR: / / Stare Work Done <br /> `'STRUCTION OF WELL: Well Diameter Approximate Depth _ <br /> Describe Material and Procedure <br /> hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> I the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> •rater completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> ELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> Eormation is t ue to the best of my knowledge and belief. <br /> IGNED <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> _ FOR DEPARTMENT USE ONLY <br /> RASE I n <br /> PPLICATION ACCEPTED BY DATE '.� J-Ty <br /> )ITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> NSPECTION BY DATE %->>_ ' . INSPECTION BY DATE -7 <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. ` <br /> E H 1426 7/72 1M <br />