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SAN JOAQUIN LOCAL -HEALTH DISTRICT <br /> FOR OTSICE USE: 1601 E. Hazelt"o"n%-7-A'v.'d"',..";j"'Stockton, Calif. <br /> Tele <br /> p o n.e,r (2,00 4t6-6781 <br /> APPLICATION FOA..WELL'I'rCON'STRUCTI"dd7:bR PUMP PERMIT Permit No. <br /> THIS ,PERMIT")EXPIRES':71-j EAR FROM DATE 'ISSUED-"-" Aydt6-f9su&d <br /> cimpl'ete-InTriplicate) <br /> 'rjoao u n I:ocalr Health l : ' ' " D `for­ ' Joaquin <br /> I . 'a':permit -toco'n"str <br /> uct <br /> and/or install the work herein described -'T - is 'made -in compiian�-, ;Ath §an Jo <br /> aqui <br /> nCounq;Ordinaneel,N&. '1862� ift4tlf4ttnj�s �4id 'Regulations' of the '�a� Joaqu n- ocage thDistrict. <br /> 9 <br /> jo t-1 . <br /> JOB ADDRESS/LOCATION <br /> 1 4 <br /> Vyy , <br /> Owner -P ne <br /> 12 1 ZzJ <br /> Addre-ps... <br /> Contractor's Name • <br /> License <br /> 71h ne <br /> DEEP N /P� DESTRUCTION /7 <br /> TYPE OF WORK (Check): . NEW WELL / <br /> EN /7 RECONDITION <br /> PUMP, INSTALLATION PUMP REPAIR —P EMtld— /7 <br /> UNP REPLACEMENT <br /> Other. <br /> DISTANCE TO 'NEAREST: SEPTIC TAN-K SEWER LINES <br /> 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 j Drilled <br /> Dia. of Well Casing <br /> Domestic/public- Driven Gauge of Casing <br /> Irrigation- ' Gravel Pack Depth of Grout Seal. <br /> Other I Rotary <br /> Type of Grout <br /> i ' Otfier <br /> Other Information <br /> PUMP. INSTALLATION: Contract- or <br /> Type- of- Pump H.P. <br /> PL* REPLACEMENT: <br /> T: <br /> State Work Done" <br /> PUMP REPAIR: State Work Done <br /> ,DESTRUCTION OF WELL., Well Diameter <br /> 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. W.ithin FIFTEEN DAYS <br /> after completion of my w6rk �on ':a new -well, I will furnish the San Joaquin Local Health District a <br /> WELL •DRILLERS REPORT of theiwell and "notify: theim before putting the well in use. The above ' <br /> infor matt is true to the]Zbest of my, knowledge and 'belief. <br /> SIGNEDI Aof- L 01 TITLE v <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY. : DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II G i IlfSPKCTIW PHASK III/FINAL-INSPECTIOL <br /> INSPECTION BY DATE INSPECTION BY DATE Z <br /> CALL FORA GROUT .INSPECTION-PRIOR TO GROUTING-AND- FINAL INSPECT N. <br /> E H 1426 7/72 IM Kms- E <br />