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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> MFOR� OFFICE USE: 1601 E. ,Hazelton Ave.; '-Stockton, Calif.- . <br /> Telephone: (209).. 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No- 73- 16f W <br /> 73 -14q <br /> THIS .PERMIT EXPIRES1 YEAR-"FROM DATE 'ISSUED Date Issued y I <br /> (Complete In Triplicate) <br /> Application is :hereby-.made-Fto 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 -and- the Rules and Regulations-'.of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION e ol: -5 CENSUS TRACT ' <br /> y <br /> Owner's Name µ ms- .: k Phone <br /> Address City " <br /> Contractor's Name a ,� (7�-. License # 26 Q 03Phone �S �`? <br />—TYPE_OF WORK-(Check) : NEW WELL /_ZDEEPEN I I RECONDITION- DESTRUCTION <br /> PUMP INSTALLATION DUMP REPAIR/ / PUMP REPLACEMENT /? <br /> f Other <br /> DISTANCE TO :NEAREST: SEPTIC TANK. �-SEWER LINES ` �G�7�'I'T PRIVY <br /> SEWAGE•DISPOSAL�FIELD n. Q( ESSPOOL/SEEPAGE_UT OTHER <br /> INTENDED 'USE TYPE OF,WELL,, CONSTRUCTION SPECIFICATIONS <br /> Industrials Cable Tool Dia, of Well Excavation , <br /> A S . r/ C <br /> Domestic/private .- Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing �+ <br /> Irrigation-1 —Gravel Pack Depth of-Grout Seal � ,C�• - �"�- � <br /> Other / otary Type of Grout <br /> Other Other Information j <br /> 1 <br /> PUMP INSTALLATION: Contractor �/r Q � <br /> fp Type of Pump r v - H.P. <br /> �---� <br /> I <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: - / / State Work Done <br /> .� <br /> ""DESTRUCTIONVOF-WELL: Well Diameter Approximate Dept <br /> Describe Material and Procedure <br /> I hereby agree to comply with all lavas 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 ofmytwork on a new well, I will furnish the San Joaquin Local ,Health District a <br /> WELT, DRILLERS REPORT+of the well and notify them before puttthe well in use. ove <br /> information is true to t best of m knowledge and belief. <br /> SIGNED2kz' /r 7� L TITLE 0-C2 C30 lo!` <br /> (DRAW P VERSE SIDE) ; <br /> FQR P MENT USE ONLYPHASE I <br /> ... <br /> APPLICATION ACCEPTED_BY ?`DATE <br /> ADDITIONAL COMMENTS: . <br /> P I GROUT INSPECTI N PHA F AL INSPECTION <br /> INSPECTION.BY_ - DATES . - - INSPECTIONW'` DATE l <br /> CALL FOR''A GROUT INSPECTION.PkIOR TO GROUTING AND FINAL INSPECTION. <br /> r <br /> 4172 lM <br /> E.H. 1426 <br />