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�' '& SAN JOAQUIN• LOCAL- HEALTH DISTRICT <br /> FOR OFFICE USE: 1.601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 73—/7 7.P <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued q..-12--73 <br /> (7C. .rf7.5,. etc_ 4�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. Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION g:;% 1d0O u al O�t W, Lr "/ ENSUS TRACT -s- 030-02- <br /> Owner's Name 4-4, 460- - Phone q3 <br /> Address n City Hca/a _CA <br /> Contractor's Name 00 License # t13 23,, "'Phone y X67 <br /> TYPE OF WORK (Check): NEW WELL / / DEEPEN /_/ RECONDITION /_7 DESTRUCTION /_ . <br /> PUMP INSTALLATION / / PUMP REPAIR /�C/ PUMP REPLACEMENT /_7 <br /> Other / / d <br /> DISTANCE TO NEAREST: SEPTIC TANK T, 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 t <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal. ' <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractors <br /> Type of Pump &A H.P. dots <br /> PUMP REPLACEMENT: / / state Work Done <br /> PUMP REPAIR: / State Work Done droA 6ki . -,,gyp � H-P <br /> ,pES_T_RUCTION 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 an -4relief. j <br /> SIGNED r <br /> �4,*�TE � 1, <br /> of (DRAW TLOYPLAIT ON REVEME SIDE <br /> F EPARTMENT USE ONLY <br /> PHASE I (� <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHA FINAL INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY DATE Z <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION, <br /> E H 1426 7/72 1M <br />