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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOROFkCCE�USE: 1601 E. Hazelton Ave. ; Stockton, Calif. <br /> Telephone: (204) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.7�-.3 6d.&) <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued,]-_24z-7-A <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 Joaquini' <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATIONS C.� / � 9_A_1W'_ <br /> I CENSUS TRACT <br /> Owner's Name flov rL Phone X6.27--_2..-7 <br /> Address.� lC � City <br /> { <br /> Contractor's Name 6 vZ, C! 1 License # Ph ; <br /> TYPE OF WORK (Check): NEW WELL DEEPEN /� RECONDITION /_� DESTRUCTION /� <br /> PUMP IN TALLATION PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DTSPO AL FIELD CESSPOOL/SEEPAGE,PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation <br /> omestic/private Drilled Dia. of Well Casing <br /> _vomestic/public Driven Gauge of .Casing <br />; _Irrigation Gravel Pack Depth of Grout Seal-l'- %s <br /> Other Rotary Type of Grout . - <br /> Other Other InformationA <br /> PUMP INSTALLATION: Contractor bg � . ? <br /> Type of Pump H.P. ^ <br /> PUMP REPLACEMENT: K / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br />( ,DESTRUCTION 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 /> acid 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 .Dist3riet a <br /> WELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> .informatio is ue to the best of my knowledge and belief. <br /> -SIGNED Ti TL - <br /> i (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 GROUT INSPECTION PHASE III FINAL INSPECTION ' <br /> INSPECTION BY _ DATE- INSPECTION BY 'DATE - 7 <br /> CALL F'OR. A GROUT INSPECTION :PRIOR TO GROUTING AND FINAL. INSPECTION. pin <br /> E H .1426 7/72 IM <br />