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r <br /> 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.,74/-�p� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued �n-7c� <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 Joaqui <br /> County Ordinance No. yy1862 and the Rules and Regulations of. the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 'I� 5, CENSUS TRACT <br /> Owner's Name /,1}L! Gl2U Phone <br /> Address ��2•3�) r/�_.�/�'7C4 ,1. .,....._ _ City S-Tzx <br /> Contractor's Name �- IIIly Jr en 2 VEC Pum, License #a Phone �-- <br /> II�I_ <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN /_7 RECONDITION /—T DESTRUCTION /_7 <br /> PUMP INSTALLATION /T,�PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other / / <br /> DISTANCE TO NEAREST: ' SEPTIC TANK. //, SEWER LINES PIT PRIVY <br /> . SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS G <br /> Industrial 1p� t,-1 Cable Tool Dia. of Well Excavation <br /> - Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public' Driven Gauge of Casing <br /> Irrigation M Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> !I� Other Other Information • ' <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump C.[ T)e /[btiQ 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 /> 'I <br /> SIGNED P -�il� TITLE R/27rNQ <br /> �I! v (DRAW PLOT PLAN ON REVERSE SIDE) - - <br /> --•- .... . _ <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> ��� <br /> APPLICATION ACCEPTED BY D E <br /> ADDITIONAL COMMENTS 11. ell <br /> PHASE III]GGROUT INSPECTION PHASE -/ - NSPECTION <br /> f INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING. AND FINAL IN T <br /> ' E H 1426 11 A ' 7/72 1M <br />