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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: l 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No 73-56 C 4J <br /> N <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. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION O / CENSUS TRACT <br /> Owner's Name ` O /j ' �1 Phone3 LgmMYsE <br /> Address (54pC&L".6— City <br /> Contractor's NameZ1cjjL- License # Phone Z,27 fs <br /> TYPE OF WORK (Check) : NEW WELL /7 DEEPEN / RECONDITION /_7 DESTRUCTION / 1 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other / / <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 r <br /> Tndustrial Cable Tool Dia. of Well Excavation I <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 i <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT- - / /- -State Work Done' <br /> PUMP REPAIR: / J State Work Done <br /> ,DESTRUCTION- OF WELL: Well DiameterApproximate Depth <br /> escri a terial and Pr edure ! <br /> .Afr <br /> r <br /> I hereby agree to ca ly with all 1a s and regulations of the San Joaqu Locaf Health Dist ict <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 and belief. <br /> SIGNED AA� TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GR UT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE // - 1L_- 9 3 INSPECTION BY DATE //- L_ 7 3 <br /> CALL FOP, A GROUT I P CTTON PRIOR TO GROUTING AND FINAL INSP CTION. <br /> E H 1426 � J 7/72 14APM <br />