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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 PUNK' PERMIT Permit No. <br /> I. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 4 -11 73 <br /> k (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> andWor install the work herein described. This application is made in compliance with San Joaquir <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION Cl CENSUS TRACT <br /> Owner's Name � � 1)eleFr�"o P-1 Phon93�Y l <br /> Address €� Tv City <br /> Contractor's Name -/, ,,�/ License # Phonel��. <br /> TYPE OF WORK (Check) : '.NEW WELL / DEEPEN /_/ RECONDITION DESTRUCTION <br /> DESTRUCTION <br /> ' PUMP INSTALLATION / / PUMP REPAIR,/ / .PUMP REPLACEMENT <br /> i; Other <br /> DISTANCE-LTO NEAREST: SEPTIC TANK. SEWER LINES PIT PRIVY <br /> k SEWAGE DISPOSAL FIELD / CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFIC&TI9PS <br /> Industrial, j; _ Cable :Tool Dia. of. We11?Excavation <br /> Domestic/private;, Drilled Dia. of Well Casing <br /> Domestic/public Driven; Gauge of Casing f m <br /> Irrigation Gravel! Pack Depth of Grout Seal ' <br /> .other' j I: Rotary.! Type of Grout <br /> Other ! Other Information <br /> PUMP INSTALLATION,* .. Contractor9 o2 <br /> r <br /> ;.Type of Pump H.F. <br /> � PUMP REPLACEMENT': I / / 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 mywork 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 :2 Q=om TITLE <br /> YMA <br /> W PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DAT -. _ r-7 <br /> ADDITIONAL COMMENTS: <br /> PHASE- II G OWf//INSPrECTION PHASE NSPECTION <br /> INSPECTION BY DATE -7 INSPECTION BY DATE <br /> CALL FOR A ` INS CON PRIOR TO GROUTING AND FINAL INSP <br /> E H 1426 7/72 1M <br />