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a <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1.601 E. Hazelton Ave. , Stockton,,, Calif, <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 7 1-- <br /> (Complete In Triplicate) <br /> Application is hereby made to 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 /> r north <br /> JOB ADDRESS/LOCATION I�d R Passide�of Latin Ed, Just =Ed& _ CENSUS TRACT <br /> of Woodbridge Rd, <br /> Owner's Name Robert Bird_ Phone <br /> Address 8.16 San L�tcafi - City _-at-ocktan - <br /> Contractor's Name San Joaquin Ramp Cn_;,,Tnr.; License # 271800 Phone Z69.-p4.71 <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN /_/ RECONDITION /—T DESTRUCTION /- <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT <br /> — 7ffjr <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial X Cable Tool Dia. of Well Excavation 1 � <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal 4-a <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> 0 <br /> PUMP INSTALLATION: Contractor <br /> Type of Pumpk H.P. „ <br /> PUMP REPLACEMENT: +' <br /> State Work Done <br /> PUMP REPAIR: / / State Work Done <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 my work on a new well, I will furnish the San Joaquin Local Health District a <br /> 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 /> SIGNED z TLE� ,- <br /> (DRAW LOT PLM N ERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I , <br /> APPLICATION ACCEPTED BY > > DATE ��� <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY P DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 - 4/72 1M <br />