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SAN JOAQUIN LOQALry HEALTIrDISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton <br /> Ave.., Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL-CONSTRUCTION OR PUMP PERMIT Permit No.7.3-z7r d(I <br /> THIS PERMIT EXPIRES 1YEAR FROM DATE ISSUED Date Issued/,—,73 31; <br /> W73 <br /> (Complete In Triplicate) <br /> Application is. hereby made .to. tI 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 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB AVVRMWLOCATION <br /> / CENSUS TRACT <br /> Owner's Name $fid o . N DY .hone <br /> Addressc- <br /> Az <br /> City <br /> Contractor's Name <br /> License 14l phone /7.4 <br /> TYPE OF WORK (Check): NEW WELL DEEPEN / RECONDITION /� DESTRUCTION /_7 <br /> PUMP INSTAL TION / PUMP REPAIR / / PUMP REPLACEMENT /_ <br /> Other / / — _ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES �40 PIT PRIVY <br /> SEWAGE DISPOSAL FIELD &L\4 CESSPOOL/SEEPAGE PIT (ff OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic , <br />_. /private Drilled Dia, of Well CasingLA <br /> Domestic/public Driven Gauge of Casing g C <br />— Irrigation Gravel Pack Depth of Grout Seal r S <br /> ------------- <br /> Other Rotary -- � <br /> Type of Grout <br /> Other <br /> Other .Information.. <br /> r <br /> PUMP INSTALLATION N <br /> Contractor O <br /> Type of Pump . H.P. <br /> PUMP REPLACEMENT: State Work Done <br /> PUMP REPAIR: / / State Work Done <br />)ESTRUCTION OF WELL: Well Diameter — <br /> Describe Material and Procedure <br /> Approximate Depth <br /> C hereby agree to comply with all laws and regulations of the San Joaquin Local Health District V1 <br /> ind the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> Lfter completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> FELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br />.nformation is true to the best of my knowledge and belief. <br /> IGNED <br /> TITLE .1 _ <br /> (D W LOT PLAN ON REVERSE SIDE -- <br /> RASE I <br /> OR DEPARTMENT USE ONLY <br /> PPLICATION ACCEPTED B <br /> DDITIONAL COMMENTS: - DATE 473 <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> 9SPECTION BY l' _i DATE - 3 INSPECTION BY <br /> DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 <br /> 7/72 IM <br />