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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. w <br /> F Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ,3- ��9 <br /> E <br /> THIS PERMIT EXPIRES 1 YEAR FROM.DATE ISSUED Date Issued , . X73 <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 />` JOB ADDRESS/LOCATION �:��.� � _ CENSUS TRACT <br /> 3'�c5 <br /> Owner's Name /4/O'�1'r1��_-- <S'�7t ? l - _ Phone C z <br /> Address <br /> City m0D c s7Q <br /> n/ License 4j 7!9k" Phone <br /> Contractor's Name T <br /> TYPE OF WORK (Check) : NEW WELL /_I DEEPEN / / RECONDITION IT DESTRUCTION. <br /> PUMP <br /> PUMP INSTALLATION /!�?'PUMP REPAIR / / PUMP REPLACEMENT <br /> Other / / �- <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE -DISPOSAL FIELD- PIT OTHER <br /> INTENDED USE TYPE OF WELL ti CONSTRUCTION SPECIFICATIONS <br /> _ Industrial Cable- Tool. Dia. of Well Excavation \A <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public t, Driven Gauge of Casing <br /> Irrigation Gravel Pack' i= Depth of Gra it Seal-,- <br /> Other" <br /> eal-'Other Rotary Type of Grout <br /> Other Other Information <br /> 1 <br /> PUMP INSTALLATION: Contractor , <br /> Type'of Pump , 1 p H.P. -_ ✓ - <br /> PUMP REPLACEMENT: /-;/ State Work Done <br /> ---. C, <br /> M_ UMP_REPAIR:,. <br /> �.��Sta•te�nTork�Done <br /> v_ - /1.I ._ <br /> C965 7VV&M0a <br /> k ,pESTRUCTION_ OF WELL: Well Diameter ' Approximate Depth — <br /> Describe Material- and Procedure r2l,, C15]S <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 /> t <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> � PHASE I <br /> APPLICATION ACCEP BY DATE <br /> ADDITIONAL CO <br /> P I G INSPECTION P II / AL INSPEC NY �� <br /> INSPECTI N ' ATE INSPE ON BY DATE <br /> CALL FOR A.GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426, 7/72 1M <br />