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k 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 <br /> f <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -/x-73 <br /> r (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 Joaquii <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION �� �1f �V�. CENSUS TRACT <br /> Owners NameZ*. W, d-7 7 '3 <br /> Phone <br /> Address Cityi7`����� <br /> Contractor's Name J 1J44; _ (� , dj� I License # 1/ ZJ Pho41dGQe-``X1— <br /> TYPE�OF WORK (Check); NEW WELL /—/ DEEPEN / / RECONDITION/_ DESTRUCTION /_7 _ <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT /. <br /> i Other / / '- <br /> � F <br /> 4 = <br /> DISTANCE TO NEAREST: SEPTIC TANK 'SEWER LINES PIT,PRIVY <br /> SEWAGE DISPOSAL FIELD - CESSPOOL/SEEPAGEr.PIT OTHER <br /> INTENDED USE TYPE OF WELL ,. q CONSTRUCTION SPECIFICATIONS r <br /> Industrial _ 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 <br /> Other Rotary Type of Grout K � <br /> Other Other Information a <br /> k � <br /> t <br /> PUMP INSTALLATION: Contractor x <br /> Type of Pump t H.P. <br /> PUMP REPLACEMENT: . / / State WorkDone <br /> PUMP <br /> REPAIR.- <br /> State Work Done ~ <br /> ESTRUCTION OF WELL: Well Diameter r Approximate Depth <br /> Describe Material and Procedure <br /> i 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 /> I information is true to the best of my knowledge and belief. <br /> SIGNED f) TITLE <br /> (DRAW PLOT PLAN ON REVERSE SID <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> k APPLICATION ACCEPTED BY, DATE '7� 2-17, <br /> ADDITIONAL COMMENTS: , <br /> I PHASE II GROUTINSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY . DATE INSPECTION BY 4. 141-116 ZA DATE <br /> - - <br /> CALL FOR A GROUT- INSPECTION PRIOR TO GROUTING AND FINAL INSPECTIO . <br /> E H 1426 7/72 1M <br />