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t <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> CATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. /,2 5'U) <br /> IS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> THIS d 00- <br /> (Complete In Triplicate) <br /> Application is hereb 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 /> JOB ADDRESS/LOCATION 3 / A CENSUS TRACT <br /> Owner's Name tki- om Ao-- Phone <br /> Addresses City ,�. ,� ., _ <br /> Contras is Name License # �� P7j-"(hone y.. (, <br /> TYPE OF WORK (Check): NEW WELL DEEPEN /_% RECONDITION /_7 DESTRUCTION /'7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP. REPLACEMENT /_7 <br /> Other / / kJv r�ri/J 6 ���i. �.la� •- .�/ _ <br /> DISTANCE TO NEAREST: SEPTIC TANK --- SEWER LINES IT IN S _ RI/ a i <br /> — � ._.._ T PRIVY - - <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS J. <br /> Industrial Cable Tool Dia, of Well Excavation C"1 <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout 5 <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. / <br /> PUMP REPLACEMENT: / State Work Done =�..I74?,// D .ta' , irk ,}.�� <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 mr knowledg_ and belief. <br /> SIGNE TITLEf <br /> RAW PLOT PLAN ON MVERSE SIDE r <br /> OR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PRASE II O INS E., ION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />