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i �4 ve 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. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 134/7;', <br /> A `2'(37"L. (Complete In Triplicate) ���1J z or7�- 1-5-0 _/� <br /> pp cation 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 ules and Reg ati s of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT C <br /> Owner's Name Phone <br /> Addresss�y L� City - - <br /> Contractor's Name Liceng_159-/�s�� Phone &9,9- 'Ye-Yb <br /> TYPE OF WORK (Check): NEW WELL / / DEEPEN /_7 RECONDITION /_7 DESTRUCTION /_ <br /> PUMP INSTALLATI N / / P REPAIRf 0 PWP RE MENT /_7 <br /> Other611 <br /> DISTANCE TO NEAREST: SEPTVC TANK SEWER LINES PIT PRIVY �^ <br /> SEWO DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER W <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 /> f ' Domestic/public Driven Gauge of Casing <br /> _ Irrigation Gravel Pack Depth of Grout Seal <br /> Other ',Rotary Type of Grout x <br /> ' E}ther Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. oz <br /> PUMP REPLACEMENT: / / State Work Done ~ <br /> PUMP REPAIR: / / State Work Done <br /> ESTRUCTION OP ,WELL:-, Well Diameter ' Approximate Depth <br /> y. . Describe Material and Procedure <br /> I hereby'4gree to comply with -all .laws and -regulations of the San Joaquin. Local Health District <br /> and the State •of California pertaining to;-.Vi 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 /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT "USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE _�!_ �. <br /> ADDITIONAL COMMENTS: ry` �— <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE - INSPECTION BY DATE 3 -/- <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> '-t�H 1426 7/72 1M t 9k <br />