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V/ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR 0 FICE USE: !� 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. '.3- ,293lJ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued _,3 <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". 2the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION ' Coov �,Q CENSUS TRACT <br /> Owner's Nameq � Phonej:ee�-- <br /> V l <br /> Address %�C elf/ ,� City <br /> Contractor's Name <br /> E�l rA,1 Idh> 13 License # 7�®6-32Fhone d-Z Z-36� <br /> TYPE OF WORK (Check): NEW WELLDEEPEN /-' RECONDITION /-7 DESTRUCTION /—]' <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANKSEWER LINES ' Q PIT PRIVY •----- <br /> SEWAGE DISP SZIELD CESSPOOL/SEEPAGE PIT OTHER --- <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial A�able Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing ,�/ <br /> Domestic/public Driven Gauge of Casing 0" <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout fry S C- , <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor ��/(,/ ljN0—/y-=- <br /> Type of Pump ."iQ R , p�!'5:4AZ H.P. <br /> PUMP REPLACEMENT: / State Work Done <br /> PUMP REPAIR: / *--S�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 /> informatin is trL— <br /> he 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 �2) DAT -26 -22 <br /> ADDITIONAL COMMENT§: <br /> PHA R UT INSPECTION PHA ECTION <br /> INSPECTION BY DATE Z 22 INSPECTION BY DATE <br /> CALL FOR A NSPECTION PRIOR TO GROUTING AND FINAL INSP I <br /> E H 1426 7/72 1M <br />