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SAN JOAQUIN LOCAL HEALTH D � <br /> FOR OFFICE:USE: .. 1601 E. Hazelton Ave- , 'Stockton; Calif,!, <br /> Telephone: (209) 466-6781 <br /> J� AP L CATION FOR WELL CONSTRUCTION OR PUMP PERMIT. P <br /> ermit No. �L <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED � ,/ ' <br /> ti Date Issued �Z <br /> �. (Complete In Triplicate) <br /> Application' hereby made to the San Joaquin Local Health District for a permit to construct <br /> and/or `ins till`they work'h'ere'in'described. This apPlication' is."made in compliance with San construct <br /> Joaquin <br /> County Ordinance No J-ill Xo-862 and.,the-Rules and Regulations' of the Sari'`Joa uin Local Health District. <br /> JOB ADDRESS/LOCATIONw f1 v` ' <br /> TRACT 04t-3,to.oLl <br /> Owner's T°Name £' 'iY ll <br /> Address M f.Llf <br /> Phone <br /> 7o S"i Al <br /> City <br /> Contractor's Name.. <br /> 1 <br /> License # 7A1wo'Phone <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN I / RECONDITION /-T DESTRUCTION /`7 <br /> PUMP INSTALLATION / / PUMP REPAIR -/X/ PUMP REPLACEMENT /7 <br /> Other.]/—/ <br /> DISTANCE TO NEAREST: SEPTIC3TANK <br /> SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT <br /> . OTHER .J <br /> INTENDED USE TYPE OF WELL <br /> Industrial , CONSTRUCTION SPECIFICATIONS <br /> xcavati <br /> Cable Tool Dia, of Well Eon rh <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 <br /> r Rotary Type of Grout j <br /> ! Other Other Information <br /> PUMP INSTALLATION: Contractor -- <br /> I <br /> Type of .Pump <br /> H <br /> .P <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: I <br /> State Work Done <br /> .DESTRUCTION OF WELL: Well Diameter <br /> - - — Approximate Depth � { <br /> Describe Material and Procedure --- <br /> I herebyp . i <br /> agree to comply with 2 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 willfurnish 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 besi of my knowle and belief. <br /> SIGNS - `� <br /> •r.. I TITLE <br /> L PLAN 0 VERSE SIDE) <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED By 6�IZ7 <br /> z/ <br /> ADDITIONAL COMMENTS: DATE <br /> PHASE II GROUT INSPECTION <br /> ECTION PHAS NAL INSPECTION <br /> INSPeBY DATE11 .. INSPECTION B <br /> DATEz- <br /> CALL FOR A GROUT INSPECTION ]PRIOR .TO GROUTING AND FINAL IN <br /> E H 1426 <br /> 4/72 1M <br />