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- SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 73- 3�6 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued / 7-3 <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 2 S _� _w O 1 F '/: D CENSUS TRACT <br /> Owner's Name ;�j 1F. WAY fitViUZZ Phone <br /> Address 4q. ,/ 11 47f- rR W City <br /> Contractor's Nance 1 J =� ,� �" �, License # `JPZ Phone'j�Ga-SS�� <br /> TYPE OF WORK (Check): NEW WELL / DEEPEN RECONDITION /7 DESTRUCTION <br /> PUMP INSTALLATION f / PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other /_7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPO AL 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 1/4 <br /> Irrigation Gravel Pack Depth of Grout Seal 16-0 <br /> Other Rotary Type of Grout <br /> -- - . _ Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / 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 /> RL ( PLOT PLAN ON REVERSE SIDE) -- - _ <br /> PHASE. I DEPARTMENT USE ONLY _ <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE JI GRO P I PHASE J�jjjFINAL INSPECTION <br />_ INSPECTION BY ATE INSPECTION BY DATE d 11215 <br /> ELL1F26 GROUT INSP TION PRIQ T�TING AND FINAL INSPE TION. 7/72 IM <br />