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n jd SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USY,: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-678.1 <br /> ICATION FOR WELL. CONSTRUCTION OR PUMP PERMIT Permit No. 7Z-3 _5K) <br /> 0 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED , Date Issued ! 0 z y 2- <br /> (Complete In Triplicate) <br /> is he� made to the San- Joaquin Local Health District for ermit 'to construct <br /> Application yp <br /> and/or install the wort° herein described. This application is. made in with San Joaquin <br /> County Ordinance No. 1862 andtheRules and Regulations Pthe San Joaquin Local Health District. <br /> ' JOB ADDRESS/LOCATION �'�[ -� �/)�S _ —_ -- - CENSUS TRACT <br /> Owners Name �� - - - -- - Phone 'eZ / 7-07e <br /> �.� <br /> Address d Y J city �10 �A 0Oil <br /> k Contractor's Names (�. �% d� S'Q_,��.__�_ _ License # J'�Phone / <br /> - �/ _ <br /> TYPE OF WORK (Check) : 'NEW WELL DEEPEN '/ / RECONDITION. /_7 DESTRUCTION. /? <br /> 'PUMP 'INSTALLATION / / PUMP REPAIR /-/ PUI4P .REPLA.CEMENT- /-7Other / / <br /> ` DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ^+,_\PIT PRIVY , <br /> SEWAGE DISP AL FIELD,.,-----,, �.G�S_SPOOL�/SEEPAGt';';P _ OTHER <br /> INTENDED USE TYPE O ELL CONSTRUCTION SPECIFICATIONS <br /> In ustrial Cable Tool Dia. of Well Excavation <br /> omestic/private Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing`'-r- a -� <br /> Irrigation Gravel Pack �Depth,�of Grout Sea <br /> Other Rotary jType of Grout <br /> 1� Other 10ther ',Information <br /> LA. <br /> PUMP' INSTALLATION: Contractor <br /> Type of .Pump H.P. <br /> PUMP REPLACEMENT: I / / State Work Done_ - <br /> �" k �. S4 <br /> PUMP REPAIR: State Work Done <br /> E <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 myi�work on a new well, I will furnish the San Joaquin Local Health District a <br /> , WELL DRILLERS O of the well and notify them before putting the well in use. The above. <br /> informati is rue t 'Ithe best of my knowledge and belief. <br /> r _ <br /> SIGNED TITLE <br /> _ <br /> (DRAW PLOT PLAN ON REVERSE SID <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I j�' — <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: II <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY <br /> i CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 4/72 1M <br />