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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.,73 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued: /e-7.3 r <br /> > (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit 'to construct y <br /> and/or install the work herein described. This application" is made in'coinpliance with San Joaquin' <br /> County Ordinance No: 1862 and the Rules and Regulations of the San' Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION e-4c12 R `/V CENSUS TRACT LJ <br /> Owner°s Name ' /I/ L Phone 6 6 <br /> Address 13111'1 <br /> _ city <br /> Contractor's Name /� B -U 4, _ License �� int v Phone <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN I_%� RECONDITION l-T DESTRUCTION /-7 <br /> PUMP INSTALLATION / PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK /A.�)/ SEWER LINES PIT PRIVY <br /> SEWAGE .DISPOSAL FIELD CESSPOOQ SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS Nr <br /> Industrial x Cable Tool Dia, of Well Excavation 12-"" <br /> Domestic/private Drilled . Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing / L <br /> Irrigation Gravel Pack Depth of Grout Seal O` <br /> Other Rotary Type of Grout <br /> 4 Other Other Information <br /> .�f <br /> PUMP INSTALLATION: kContractor <br /> of Pum _.3 <br />_ Type p H.P._. _ <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: 1-7 State Work Done <br /> J ,PESTRUCTION OF WELL: We/YIII ZWer �` �r f Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with alI laws and regulations of the San Joaquin Local Health District <br /> i and the State •of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> 4 after completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> f 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 /> r <br /> SIGNED1zrl v TITLE <br /> (DRAW PLUT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> ! PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: ,i' <br /> PHASE I)ITG OO S T PHASE III FINAL INSPECTION <br /> INSPECTION i BY Z DATE /- INSPECTION BY _- DATE //-6'7-- _ <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. 1 .41 <br /> 7/72 IM <br /> E H 1426 <br />