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` '�T�/SAN AOAQUIN LOCAL HEALTH DISTRICT <br /> FOROFFICEUSE: 1.601 E. Hazelton'.Ave. , Stockton, Calif. <br /> Telephorie:'.'.. (209).,466-6781 <br /> APPLICATION FOR -WELL CONkRUCTION-OR -PUMP PERMIT Permit No. -72,-61 <br /> IN THIS PERMIT-­EXPIRES 1--,1'EAR, FROM:DATE ISSUEDDate Issued (a'z3 72-, <br /> hJ " .(Complete iIri Ttiplitate) <br /> Application);i:�; ereb� de[:to t­he-),SaniJoaquin- Lo'ca1 Health District- for a permit to- construct <br /> and/or install the work herein described. This;,application­id made in compliance with San Joaquin <br /> County Ordinance,,No.. 18 62- and ith& ,Rtiles'= and,..Regulations,, of:-the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATIONCENSUS TRACT <br /> IQ <br /> 7 <br /> Tv <br /> Owners�Nage.;1 Phone <br /> Address <br /> City h4—:7-g-& <br /> Contractor s Name 10 License # 42371. Phone Y66- ,0 <br />! <br /> i TYPE <br /> _90TYPE OF WORK (Check) : KNEW WELL DEEPEN -RECONDITION DESTRUCTION- /_7 <br /> PUMP INSTALLATION Pump REPAIR I I PUMP REPLACEMENT <br /> , Other ./ ./ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL YIELD V ,,,CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE . TYPE OF WELL 5 CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable ToolDia. of Well Excavation PIZ—_____i <br /> Domestic/private! - Vrilled�-- --, ii\ Dia. of Well Casing <br /> Domestic/public . . .Driven' " Gauge of Casing <br /> ­C, \ . <br /> Irrigat 'Gravel'Grai Pack Depth of Gr'out Seal <br /> Other Rotary- Type of Grout <br /> Other Other Information D <br /> '"PIT <br /> PUMP INSTALLATION.- Contractor <br /> Type 'of Pump <br /> %;NA <br /> PUMP REPLACEMENT. State Woik_Dke'_- <br /> PUMP REPAIR: State Work Done <br /> ­;DESTR_UCTTON' OF WELI;: _ � Wdll D I a'm_d fte�i ` <br /> Approximate, Dep-th—�­� <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 CalifS.rnia pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> after completion of my$work on a new well, I will furnish the San ,7'oaquin 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 t4the best of my knowledge and belief. <br /> SIGNEDTITLE.' <br /> -11:4 V &I", <br /> j (DRAW PLOT AN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS.- !11: U, <br /> PHASE Il GROUT INSPECTION PHAEJIII/FINAL INSPECTION <br /> INSPECTION BY % DATE INSPECTION BY DATE . <br /> CALL FOR A - <br /> GROUTIAPECTLON.PRIOR TOGROUTINGAND-FINAL INSPECTION. <br /> H 1'426 4/72 1M. <br />