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SAN JOAQUIN LOCAL REALTH 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. 3,� ye z.-J <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued - -76 <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 v / ®D .D CENSUS TRACT <br /> Owner's Name Phone _ <br /> Address SKA1 E D j Cityl-LW <br /> Contractor's Name s1LL/ License # 117,-%,1 Phone <br /> TYPE OF WORK (Check) : NEW WELL, DEEPEN /-7 RECONDITION /-7 DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST:_ SEPTIC TANK SEWER LINES PIT PRIVY = <br /> -.-SEWAGE 'DISPOSAL-FIELD- - •-----r-CESSP00L'/-SEEPAGE -PIT :: OTHER- ,--- <br /> INTENDED <br /> THER- .INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial 'Cable Tool Dia. of Well Excavation U <br /> _ Domestic/private Drilled Dia, of Well Casing _ �T <br /> Domestic/public Driven Gauge of Casing _�J �4 , <br /> Irrigation Gravel Pack Depth of Grout Seal' N <br /> Other Rotary _ Type of Grout <br /> Other rtOther Iitformation <br />• ah � T <br /> PUMP INSTALLATION: Contractor �� <br /> Type of Pump i H.P. <br /> 1 <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done 1 <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. �.v7xrw vA <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I l� <br /> APPLICATION ACCEPTED BY DATE / <br /> ADDITIONAL COMMENTS. <br /> PHASE II GROUT INSPECTIO r PHASE-I1,I/FINAL INSPECTION <br /> INSPECTION BY / DATE /.� --/lU INSPECTION BY `` DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION <br /> E H 1426 7/72 1M <br />