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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton.:Ave," <br /> A" <br /> ; Stockton, Calif. <br /> Telephone: i t(209)v"466-6731 <br /> ' <br /> 'APPLICATION FOR WELL CONSTRUCTIOW.OR PUMP PERMIT Permit No. <br /> 2-- .q3 <br /> THIS PERMIT EXPIRES I..YEAR FROM"DATE `ISSUED <br /> ., = —Date Issued �7Y <br /> (Com Tete In-T•r�iplic ate} <br /> Applicatiaxi'is�hereb �i&de xto the�SangJoaqurn 'Local flealth District >16ri:a permit to construct <br /> and/or install the work= herein described. Th�s.,app1acation is .made= <br /> Count OrdinancecNo ,18.62�,and,�the -Ru;lesL.and ,Regulations ,of,ethe,San=Joaquin pLaCaleHealthl}istrict San -Joaquin <br /> .TOB Y' l -o <br /> ADDRESS/LOCATION <br /> IS C, Z2 CENSUS TRACT <br /> Owner.s:.Name <br /> 14 :Phone':, �s y°" 40 <br /> Address �D —� C F9 Api?/ <br /> . City <br /> Contractor's Name i2/ <br /> License. # 06 O/ Phone <br /> TYPE OF WORK (Check} : . NEW WELL/ // DEEPEN / / RECONDITION /_7 DESTRUCTION <br /> PUMP INST:4L�.,ATION /� <br /> .d. / PUPiP REPAIR :.PUMP REPLACEMENT /_ <br /> Other:. / / f <br /> DISTANCE TO NEAREST: SEPTIC TANK ,.. <br /> TANK = ... SEWER LINES PIT PRIVY P <br /> 3 SEWAGE. DISPOSAL FIELD 1�7 CESSPOOL/SEEPAGE PIT OTHER ' <br /> J1. <br /> ' INTENDED USE TYPE OF WELL <br /> CONSTRUCTI <br /> Industrial ON SPECIFICATIONS <br /> Cable Tool Dia. of Well Excavation <br /> Domestic � . � <br /> /private Drilled Dia. of Well Casing <br /> Domestic/public <br /> Driven,, , Gauge of Casing <br /> Irrigation Gravel <br /> �Pack Depth of Grout Seal <br /> Other Rotary0. <br /> Type of Grout <br /> 13 - LA <br /> Other' Other Information ' f <br /> PUMP INSTALLATION; Contractor <br /> Type of Pump <br /> I�. H.P. . <br /> PUMP REPLACEMENT: / i/ State 'pork Done <br /> PUMP REPAIR: State Work Done <br />,AESTRUCTION OF W <br /> ELL: Well Diameter <br /> De�s! cribe Material and Procedure Approximate. Depth <br /> I hereby agree to camply .;taith all laws and regulations of the San Joaquin Local Health District <br /> and -the State of Cal'ifory a 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 <br /> C." <br /> E <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY �T <br /> A _ <br /> ADDITIONAL COMMENTS: DATE ' ' S' —72 <br /> a <br /> PHASF4 II GROi..T INSPECXZPN <br /> INSPECTION BY PHASE II/FINAL INSPECTI N <br /> ilk" DATE INSPECTION BY G DATE �{ <br /> CALL-F'OR,A_GR_OUT. INSPECTION„PRIOR. GROUTING AND FINAL INSPECTIO <br /> E H 1426 - - - 4/72 1M <br /> , i <br />