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ec <br /> .cam`-' SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> rOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> 1 Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ,/p.- 7�1 <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 n the es Regulations of the San Joaquin Local Health District, <br /> JOB ADDRESS/LOCATION c.a ,dFA O P 4.I`3 P F,o If 7A 1c h, /gy p CENSUS TRACT <br /> Owner's Name Phone ! <br /> Address 3 5- S- :Z�' - _ - ---- City S C- '-f . <br /> Contractor's Name !" License #lggo;—py Phone 74,f-10r-A. <br /> TYPE OF WORK (Check): NEW WELL DEEPEN /7 RECONDITION /7 DESTRUCTION /_ <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other — — <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> > i <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS f <br /> Industrial Y. Cable Tool Dia. of Well Excavation s`a' <br /> Domestic/private Drilled Dia, of Well Casing Aft 1;3 <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout. Seal b ' <br /> Other Rotary Type of Grout F ,P�t� <br /> Other ether Information <br /> I Q14 <br /> PUMP INSTALLATION: Contractor- f I G <br /> Type.,o f Pump, .-, H.P <br /> PUMP REPLACEMENT: / / State Work Done V'r. <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 /> 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 �t•� , TITLE �li.✓u _ <br /> (DRAW PLOT' LAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE*ONLY <br /> E PHASE -I .� ........ _ `` <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> P SE GROUT INSPEC ION 1PHIAII14FINAL INSPECT NINSPECTION BY DATE INSPECTION BDATE �3CALL FOR A OUT INSPECTIQN PRIOR TO GROUTING"'AND FINAL INSN: <br /> r E H 1426 7/72 1M <br />