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�� SAN ,30AQUIN LOCAL HEALTH DISTRICT � <br /> FOi.:01i E SSE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 'a <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 30 - 3 <br /> (Complete In Triplicate) <br /> Application is hereby made toithe San Jo Local Health District for a permit to construct <br /> and/or install the work herein described. , This application is made in compliance H a1C1�$Dis riet�n5 <br /> County Ordinance No. 1862 and <br /> jthe Rules and Regulations of the San Joaquin <br /> .308 ADDRESS/.LOCATION <br /> M CENSUS TRACT <br /> Phone <br /> 'Owner's NamePA"v <br /> —A"_ <br /> Address <br /> c 5,�- City . .�°C�-' <br /> License # 1 3?ZPhone 2" <br /> Contractor's• Name ' <br /> TYPE OF, WORK (Check) : NEW WELL / / DEEPEN RECONDITION / pEREPLAC MENT�I_7 <br /> PUMP INSTALLATIONMP./ / PUREPAIR / / — <br /> Other J!/ <br /> •Y <br /> PRIVY <br /> DIST TO NEAREST: SEPTIC TANK SEWER LINES PIT C � <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS i <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Drilled Dia. of Well Casing <br /> Domestic/private Driven Gauge of Casing <br /> Domestic/public <br /> Irrigation Gravel Pack Depth of Grant Seal <br /> Other <br /> Rotary Type of Grout <br />�� -- Other Other Information - <br />. --'-' <br /> PUMA' INSTALLATION: Contractor <br /> Type-iof Pump -,,a 4 'm&2--- <br /> PUMP REPLA„ CErIEIIZT:� --� SCate Work Done <br /> # .�-- .� � <br /> PUMP REPAIR: v / / State Work hone - <br /> ' , Approximate Depth 1 <br /> 11 ,DFRTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure <br /> I hereby agree to comply'with all laws and" regulations of the <br /> construction.Local <br /> Health <br /> in lt District <br /> acid the State of California pertaining to or regulating well <br /> after completion of my work on a new well, I wi1l ._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 knowl,edg belief. <br /> fITLE <br /> SIGNS PLOT PLAN ON R RSE SIDE) <br /> FOR DEPARTMENT USE ONLY ' <br /> PHASE I L DATE. 3 7 <br /> f, APPLICATION ACCEPTED -BY <br /> r4 ADDITIONAL CpI�]ENTS: � 1 <br /> } PHAS II/F NAL INSPECTIO 1 <br /> PHASE Ii OUT INSPECTION INSPECTION BY DATE <br /> INSPECTION BY DATE <br /> Y t <br /> CALL .FOR A GROUT-INSPECTION•PRIOR..TO GROUTING AND .FINAL INSPECT ON. <br /> .5/73 <br />