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e <br /> 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. Z2_J 3 <br /> op <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued /�_-i�-7yf <br /> (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 Joaquin; <br /> 'County Ordinance No. 1862 and the Rules and Reg u tions of the San Joaquin Local Health DistrictY <br /> JOB ADDRESS%LOCATION yy�� <br /> ENSUS TRACT cS qj <br /> Owner's Name � -- <br /> Phone 3 33 Y1 <br /> Address 7 f City <br /> Contractor's Name � � - / <br /> License #/4 13 73 Phon � <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN' /�% RECONDITION'/_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR PUMP REPLACEMENT /_ <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK " SEiR LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL � <br /> ' .r CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tobi Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation I 'Gravel Pack <br /> Other . <br /> Depth of Grout Seal <br />-��..r Rotary Type of Grout <br /> Other. - Other Information k <br /> PUMP INSTALLATION Contractor <br /> Type ,of Pump <br /> H.P. <br /> PUMP REPLACEMENT. / / State Work Done 4 <br /> PUMP REPAIR: State Work Done , , <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> 1 <br />[ hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> ind 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 /> BELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> Lnformation is true to the best'; of my knowledge and belief. AiIGNED <br /> w: I <br /> TITLE, /J�1 <br /> (BRAW PLOT PLAN ON REVERSE SIDE <br />'RASE I <br /> FOR DEPARTMENT USE ONLY <br /> � <br /> APPLICATION ACCEPTED BY BATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE I I FINAL INSPECTION <br />',NSPECTION BY DATE INSPECTION BY DATE-3!3 - <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. - <br /> E H 1426_ 7/72 1M <br />