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SAN JOAQUIN LOCAL I-EALTH DISTRICT 171 <br /> FOR OFFICE—USE- 1601. E. Hazelton Ave. , Stockton, Calif. � ►J -/ <br /> Telephoner (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. L C F <br /> '? V 7 3 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued J 17 7 Z <br /> '77C S 7 (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 /> JOE ADDRESS/LOCATION 0-1- 141 W,4'1 5-o Ny To 7/?Ae-Sf— - CENSUS TRACT <br /> Owner's Name 7 ID. R R 17 V L I Phone 46& - i!U z- 7 <br /> Address x0.2 3 IV, S U- "T.`j EP S 1 S %f-N City r 'T/CNC 6t-1fi <br /> Contractor's Namef ri/111Ir'�/Z Sid L 6e,AYP-t �7 /G License # 6 ,�I Phone 464 98 <br /> TYPE OF WORK (Check) : NEW WELL /9- DEEPEN /`7 RECONDITION -/7 DESTRUCTION /7 <br /> -'- ` PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /7 <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 Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia, of Well Casing C <br /> X Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout -: <br /> Other Other Information <br /> Y� <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump §' ru� —_-- H.P. �s~� <br /> PUMP REPLACEMENT: / / 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 TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I / <br /> APPLICATION ACCEPTED BY � cb DATE 7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASFY FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE - f <br /> / - <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL IN CTION. <br /> E H 1426 4/72 1M G,5 <br />