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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE US : 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: .(209),466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.IfL_ <br /> THIS -PERMIT EXPIRES ;1 YEAR FROM DATE ISSUED Dat e' Issued 3 1=�S <br /> -(Complete In`Triplicate) o—zCl <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 'to' cal Health District.' <br /> JOB ADDRESS/LOCATION, c� �Gf�:� t pQ�ve,• !!��c�wcc"r 1f �r� CENSUS- TRACT <br /> Owner's Name Ale At2 ��` `,:�' y ,.� .,( Phone`"yG�c <br /> Address 9'39 _Ui'. Lrr� {r _ .. �.._. y ---- _ _Cit <br /> Contractor's Name / " A� 1h r, r License # Phone 972- /r5-F <br /> TYPE OF WORK (Check) : NEW WELL X7 DEEPEN / / RECONDITION /_7 DESTRUCTION /_7 �- <br /> PUMP INSTALLATION _W PUMP REPAIR / / PUMP REPLACEMENT /7 11Z <br /> Other J f ti <br /> N <br /> DISTANCE TO NEAREST: SEPTIC TANK L� �FISEWER 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 o �+ <br /> Other Rotary Type of Grout <br /> iccS4v <br /> Other Othex Inf rmat on}( x4ot 4 <br /> F <br /> PUMP INSTALLATION: Contractor / p k.c <br /> Type of Pump _ . ��._ C}cfs�. - H.P. <br /> PUMP REPLACEMENT.- State 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 � � -c Y DATE /Z3 <br /> ( ADDITIONAL COMMENTS: <br /> PHASE II PROUT INSPECTION PHASE I1j/FINAL INSPECTION <br /> INSPECTION BY ATE ,7 INSPECTION BY DATE <br /> CALL FOR A GROUT INSPE ION PRIOR TO GROUTING AND FINAL INSPECTION, <br /> E H 1426 7/72 1M <br />