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SAN JOAQUIN LOCAL HEALTH DISTRICT � �T <br /> FOR OFFICE USE: /APPLICATION <br /> .601 E. Hazelton Ave. , -Stockton, Calif. _6 Y47 <br /> Telephone: (209) 466-6781 <br /> FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> r C?gIL j <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued ,S-/6 70, <br /> .I - (Complete -In•Triplicate) -- - <br /> Applicatioin' is herebyamadeito :the^ San Joaquin Local Health District fox a permit to construct <br /> and/or install the work herein described. This •applicati-on is made in compliance with San Joaquin <br /> County Ordinance No:�1862-:and*the Rules and Regulations of the San Joaquin Local Health District.- <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> .X.. r 7 7 , <br /> Owner'sName' .` - <br /> Phone <br /> Address Q n. 0J-_o -� it "� Ja i - <br /> r-1 city <br /> Ilk <br /> Name License it/n,1_0,Phone-ZJLY-/3 Y7 <br /> TYPE OF WORK (Check) : NEW WELL '/� DEEPEN /_/ RECONDITION /_/ DESTRUCTION/_ <br /> PUMP INSTALLATION /—/ PUMP REPAIR I I PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER V% <br /> - <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPEC NS 6 <br /> Industrial c_-�Ie Tool Dia, of Well Excavation ;2 �p e <br /> gestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing . /,z- <br /> Irrigation <br /> ,Irrigation Gravel Pack Depth of Grout Seal S A <br /> Other Rotary Type of Grout y �„ s <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P.ZL <br /> PUMP REPLACEMENT: J I State Work Done <br /> PUMP-REPAIR:max./r/_,S.ta.te< Work;-Done - - - <br /> :DESTRUCTION OF WELL: Well Diameter <br /> 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 and belief. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR D ARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY1�4 5'DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE 11�3 / INSPECTION BY DATE <br /> CALL F'OR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 4/72 1M <br />