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Y <br /> :0�'FICL USE: � SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> t�0�'. <br /> ��� t1601 E. Hazelton Ave. , Stockton, Calif. <br /> 11 - Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7�1- J20/0 <br /> i <br /> j THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 3__7_5--74L <br /> ,i (Complete In Triplicate.) "A.) : l.-7- /a -06 <br /> Application is hereby made to the Sart Joaquin Local Health District for a permit to construct <br /> and/or install the work herein described. ' This application is made in compliance with SanJ.baquin ' <br /> County Ordinance No. 1862 and the. Rules and Regulations of the San Joaquin Local HeaYth District. <br /> JOB ADDRESS/LOCATION �ENSUS TRACT ' <br /> Owner's Names - Lt C� ie re r _ Phone <br /> Address _- 252 A_�- - � xal- _ City <br /> Contractor's Name ._ d License # S_Phone : f <br /> TYPE OF WORK (Check) : -NEW WELL / / DEEPENL/ RECONDITION / / DESTRUCTION /_7 <br /> PUMP INSTALLATION PUMP REPAIR'/—/ PUMP REPLACEMENT <br /> 6sther / / — <br /> DISTANCE TO NEAREST: SEPTIC TkNK 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 <br /> 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 /> .Ib <br /> F <br /> PURR' INSTALLATION: Contractor <br /> Type of Pump H.P. • -' <br /> j� <br /> PUMP REPLACEMENT: / State Work Done `a�� <br /> IN <br /> PUMP 'REPAIR: /I / Stave Work: Done <br /> U <br /> .DF'zTRUCTION 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 'construttion. 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 ofl'the well and notify them before putting the well in use. The above <br /> information is true to the best of my. owled e b F ef. <br /> SIGNED — E _ <br /> j. ( ON REVE E SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I Z.1 <br /> APPLICATION ACCEPTED -BY DATE <br /> ADDITIONAL COMN,ENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY. ; DATE INSPECTION BY DATE <br /> 1�' <br /> CALL FOR A GROUT -INSP,ECTION: PRIOR TO .GROUTING -AND -FINAL INSPEC ION. _..,'° <br /> E H 1426 ii 5/731x2 � <br />