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r ,. SAN JOAQUIN LOCAL RrALTTI STRICT' <br /> OR O <br /> FtUSE:. 1601 E. Hazelton'Ave. , Stockton, , Calif.Call:f <br /> Telephone:' (209) 466�6781 <br /> PLICATION FOR WELL-CONSTRUCTION 'OR PUMP PERMIT Permit No. J 7- '5/ <br /> THIS PERMIT EXPIRES 1 YEAR-MOM DATE 'SSUED r Date 'Issued 6 -17--71, <br /> (Complete In,Triplicate) <br /> Applicat0n`i6,hereby-ma a;Ito ihe.rSan -Joaquin' Local'.`Hea1th DiatticC fori,a permit to construct <br /> and/or install the work herein described. This apl lication is made in compliance with San Joaquin <br /> County. Ordinance No @. _1862,and,:the- Rul:es ,and. Regulations -of ;the San Joaquin Local Health District. <br /> : .TOB ADDRESS/LOCATION / ' CENSUS TRACT <br /> Owner`s Name s k ..,: _ Ph <br /> oine 5`� <br /> Address. �� _._. -- - city <br /> ` Contractor's Name .` License. #v2 , —,z Phone ` 9 <br /> I <br /> "< ..,TYPE OF WORK (Check) : NEW WELL DEEPEN /? kECOXbITION /- DESTRUCTION /7 <br /> - _ PUMP INSILLATION / PUMP REPAIR /�/ PUMP REPLACIiaMENT /� <br /> ' Other, / / <br /> -DISTANCE TO NEAREST: SEPTIC TANK S SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS „ <br /> ► Industrial Cable Tool Ilia. of Well ExcavationIX <br /> I Domestic/private Drilled Data. of Well Casing I' <br /> Domestic/public Driven Gauge of Casing <br /> Ir,rigati.on Gravel Pack Depth of Grout Seal <br /> Other Rotary " .Type.of,Grout <br /> Other Other Information " <br /> PUMP iNS <br /> 'fALLATION: Toneof <br /> rtPump <br /> .. <br /> P <br /> PUMP REP <br /> / State Work�Don� 6 � <br /> LACEMENT: .. . .�one <br /> PUMP REPAIR: / / State Work Done ; <br /> . E$TRUCTION 0F, WELL.:_ �_We1I.Diameter,:_ -Approximate_ Depth x <br /> P- -- .-- <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> y 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 Sari 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 s true. to the best of -my knowledge and belief. <br /> SIGNED . TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOP. DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY <br /> _ . DATE W/ <br /> ADDITIONAL CO-M MENTS: el <br /> PHAS I.I GROUT INSPEC I©N PHASE III FINAL INSPECTION <br /> INSPECTION BYDATE �,; INSPECTION BY . . <br /> 7 7l ��..:.,..:.� DATE 7� <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> 142 <br /> 1 <br /> 4/72 IM E..H 6 _. . <br />