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'. SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO er E USE: 1 1.601 E. Hazelton. Ave. , 'Stockton, Calif. i <br /> Telephone: (209) 466-•6781 " <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 3'-/�3 k <br /> ` - .%A 73 -1br <br /> THIS 'PERMIT EXPIRES 1 YEAR 'FROM DATI. ,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 �cal Health District. <br /> gs JOB ADDRESS/LOCATION p V CENSUS TRACT ' <br /> d r;v M�2 Iry Co wf_z_ <br /> Phone <br /> Owner's Name Pi iy 0Jv� i= ! rpt-f` �+2 - <br /> Address �- City <br /> i <br /> Contractor s Nam <br /> p� �� �'C(C� Phone ,0 3c <br /> License f <br />•-STYPE-OF-�WQRKT(Cl-eck�) :-NEW;WELD/�� EPEN '/_/�RECONDITIQN /�]'04a;� e- <br /> DESTRUCTIONF/�`� <br /> PUMP INSTALLATION /4 PUMP REPAIR m/ / PUS' 'REPLACEMENT /?".,� ; <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK_Sj_� SEWER-, 'INES� > PIT PRIVY <br /> SEWAGE DISPOSAL FIELD } ` CESSPOOL/SEEPAGE FIT OTHER <br /> INTENDED- USE TYPE OF WELL CONSTRUCTIONmSPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation !/ <br /> �mestic/private Drilled Dia. of Well Casing �o f` i±,l <br /> mDomestic/public,, Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal. i op <br /> Other Mary Type of drout t Al-i <br /> Other Other "Information m <br /> S• <br /> J PUMP INS16LLATION: Contracto - l <br /> 1 Type of Pump. H.P. , <br /> 9 <br /> PUMP REPLACEMENT: / / State Work Done` <br /> PUMP REPAIR: / / State Work Done <br /> DESTRUCTION 0 W L_L:' Well-Diameter Approximate Depth <br /> Describe Material and,-Pr'ocedi►re <br /> ( I hereby agree to comply with all laws and regulations of the San 'Joaquin Local. Health District <br /> 1 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 th��--��""��ell and notify them before putting the well in use. , The above <br /> infor do ue to �st of my o ,ledge .a belief. <br /> i <br /> SIGNEDTITLE _ [�v•,C3 rrntltR/' -Y�. <br /> 1 W .PLOT PLANm ON .REVERSE' SIDE) <br /> FOR PARTMENT'USE ONLY ` '_. -_ - • <br /> ` PHAS DATE" <br /> 7�- 4 -- <br /> APPLICATION ACCEPT B / -- <br /> ADDITIONAL CO <br /> P S II OUT INSPECT N F I� AL INSPECTION _ <br /> INSPECTI BY DATE INSPE ON BY DATE "i <br /> ' CALL FOR A GROUT INSPECTION PRIOR TO GROUTINGmANDrFINAL INSPECTION. <br /> 4/72 1M <br /> E H 1426 - <br />