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/?l SAN JOAQUIN LOCAL HEALTII 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. <br /> �7z-1-2 <br /> THIS PERMIT EXPIRES 1 YEAR. FROM DATE "ISSUED ; Date Issued �p�3i-73 <br /> (Complete In Triplicate) <br /> k Application is hereby made to the San Joaquin Local. HealthDistrict for a permit to construct <br /> and/or install the work herein described. This application n <br /> is made in with San Joaquin <br /> ' County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local. Hea th District. <br /> JOB ADDRESS/LOCATION /� 1Al. O lC11 P DRI US TRACT <br /> nn ` <br /> Owner's Name Phone .� <br /> Address _' .0 City LOo44r <br /> Contractor's Name •rCA <br /> ILLI v License �� //%2 / Phone; �o(f�- 43 <br /> ('C�heck") " NPUEWNIP % -7 <br /> TYPE TYPE OF WORK � �] a <br /> 'IN5T4GTbN"t PU -REPAC <br /> Other <br /> i / ! <br /> DISTANCE ;TO NEARESTi `SEPTIC TANK SEWER LI*S PIT PRIVY �^ <br /> . . .SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> 4 . <br /> INTMED USE -1 TYPE OF WELL CONSTRUCTION SPECIFICAT ONS <br /> Industrial ;, Cable Tool 1 Dia. of Well Excavation f44 <br /> Domc�Stic/.private ` Drilled Dia. of Well Casing Q <br /> Domestic/public` Driven Gauge of Casing A? . - <br /> Irrigation Gravel Pack ,Depth of Grout 'Seal 4�--_— V' <br /> Other, Rotary Type of Grout c - <br /> .iOther � Other Information �---- <br /> PUMP INSTALLATION ' "Contractor��� <br /> Type .of Pump >� �" !! H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> j <br /> PUMP-REPAIR: �` /�/ State Work Done <br /> r�.RESTRUCTION OF WELL: Well Diameter ate: Approximate Depth <br /> - -- - -- - <br /> Describe Material and Proc ure <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 regu*ting well construction. Within FIFTEEN DAYS <br /> Jj- <br /> after completion of my work on a new well ' I will 'furnish the San Joaquin Local Health District a <br /> WELL DRILLE SREPORT of the well and notify them before putting the, well in use. The above <br /> informaXlgue to the best of my knowledge and belief.SIGNED a TITLE <br /> (DRAW PLOT PLAN ON REVERSE. SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I. t <br /> APPLICATION ACCEPTED BY �i r�i__ DATE ' /G ` ?-7-7 Z--- <br /> j ADDITIONAL COMMENTS: Ia <br /> PRASE IIIIGROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY iI DATE INSPECTION BY DATE ,` " 7 <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 4/72 1M <br />