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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. 73- 071d <br /> r THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date. Issued.--* <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 thq Rules a 'd Regulations of the San Joaquin Local Health District. <br /> J1.4,171 `C R� Qor i . <br /> JOB ADDRESS/LOCATION F; l 1 L .,RNSUS TRACT <br /> Owner's Name 4 1gJ SAP 1 Phone <br /> Address I/1//VJAI C, .- � , _�4SJ • . ty Cif�-�-� . . <br /> /14 <br /> Contractor's Name ,�{� - License Phone l <br /> TYPE OF WORK (Check) : NEW WELLDEEPEN /_/ RECONDITION /-7 DESTRUCTION /-7PUMP INSTALLATION / PUMP REPAIR /—/ PUMP REPLACEMENT /7 <br /> Other /-7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> _ Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing C <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout I <br /> Other Other Information <br /> �i <br /> i <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: <br /> / / State Work Done <br /> PUMP REPAIR, State Work DoneY <br /> DESTRUCTION OF WELL: Well Diameter 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 /lam•• TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) - <br /> �) FOR DEPARTMENT USE ONLY <br />?HASE I <br /> APPLICATION ACCEP BY Az- l E <br /> ADDITIONAL COMMENTS: j JA <br /> PHASE II GROUT INSPECTION P Sff�NINSPECTIQN <br /> INSPECTION BY DATE INSPECT BY ATE -� <br /> CALL FOR A GROUT' INSPECTION PRIOR TO GROUTING AND FINAL .INSPECTION. 9 <br /> E H 1426 _ 7/72 IM <br />