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{ f USAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: � 1601 R. Hazelton Ave. , Stockton, Calif. <br /> Telephone; (209) 4f6-6781 j <br /> V LICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 2 U3/ <br /> ,p r� <br /> 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. 1$62 and the Rules and Regulations_ of the San' Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 1- /^ CENSUS TRACT <br /> Owner's Name # Phone ► <br /> Address City X11 <br /> Contractor's Name. Qs'/ License # / y, Phone ,-" � <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN RECONDITION /— DESTRUCTION /? <br /> k PUMP INSTALLATION / / PUMP REPAIR / / PUMA REPLACEMEN /_ <br /> t Other ./ / d : VLI <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 F Cable Tool 'Dia. of Well Excavation" . <br /> Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public _ Driven Gauge of Casing <br /> Irrigation _ ...Gravel Pack Depth of-Grout Seal r <br /> Other Rotary Type of Grout i� <br /> Other Other Information O <br /> .�•--r <br /> PUMP INSTALLATION Contractor t +�- <br /> Type of Pump H.P. / <br /> PUMP REPLACEMENT: / / State Work Done <br /> f o <br /> 4, PUMP REPAIR* / / State Work DoneAlex) �. ;� <br /> }J) STRUCTION 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 Locil-Health District <br /> and the State -of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> laf.ter completion of my work on a new well, I will furnish the San Joaquin Local Health Distritt a <br /> WELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> �. .riformation is true to the best of my knowledge and belief. <br /> SIGNED &_ Ir,—,-7,1 0 �%g - <br /> TLE 00 <br /> (DRAWaLE PLAN ON REVERSE SIDE <br /> ffR DEPARTMENT USE ONLY <br /> ' PHASE I DATE f3�zr� <br /> APPLICATION ACCEPTED BY- <br /> DATE <br /> - <br /> PHASE- II GROUT. INSPECTION PHASE II FINAL INSPECTIQN <br /> }INSPECTION BY . DATE INSPECTION BY DATA <br /> r <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br /> 1 , <br />