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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR `OFFICE USE: 601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (204) 466--6781 <br /> PLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. _6 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE "ISSUED , Date Issued 2 3. 7 L <br /> i. <br /> i (Complete In Triplicate) <br /> Application is hereby-made 'to_,the San Joaquin Local Health Distract 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-erd the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION .S -p.(, CENSUS TRACT <br /> ii <br /> Owner's Name -�f'.S ��tl w�ir- ,� �L ,(� PK D 9 _ Phone 292 <br /> - <br /> Address 674 tn16 City <br /> Contractor's Name ® S License �� " Phone . -amu <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN I / V RECONDITION/-7 DESTRUCTION /-7 <br /> PUMP INSTALLATION I. I PUMP REPAIR '/—/ PUMP REPLACEMENT /? t <br /> Other ! 1 <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 3 <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 ' <br /> Other Other'Information " <br /> � g <br /> E. PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> i <br /> i <br /> CPUMP REPLACEMENT: / / State Work Done ` _ 6 <br /> PUMP REPAIR:- F .-,/TT=StateWork-- Done -A p_ <br /> ,PESTRUCTIONOF 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 /> f information is true to the best of my knowledge and belief. <br /> k <br /> SIGNED AeCn TITLE <br /> (DRAW PLOT LAN ON REVERSE SID <br /> FOR WPARTMENT USE ONLY <br /> i PHASE I <br /> APPLICATION ACCEPTED BY DATE , <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> t INSPECTION BY �— DATE "�� INSPECTION BY , DATE <br /> I CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> 4/72 1M <br /> E H 1426 <br />