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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OYFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif„ <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.72-5--21 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ? o- 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. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRES S/LOCATION A 3 00 W, /j R M v Nr R© CENSUS TRACT <br /> Owner's Name U-,, _1('A 7-,&-IV aA1)?V Phone 36S, 7e o z. <br /> Address -- _i73 00 cy 4 2M 3 7-/?oAlg fq U City Lop 1 G.jqe- <br /> Contractor's Name ' � License #sGs& 1 Phone 4;�qg 35! <br /> TYPE OF WORK (Check): NEW WELL /-7 DEEPEN /-7 RECONDITION /-7 DESTRUCTION /-j <br /> PUMP INSTALLATION / / PUMP REPAIR ZK PUMP REPLACEMENT /7 <br /> Other /-7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation U5 , <br /> Domestic/private Drilled Dia. of Well Casing O <br /> Domestic/public Driven Gauge of Casing O <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / J State Work Done <br /> PUMP REPAIR: / State Work Done � �, t ,,,� 3, r? � <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 c. le, TITLE <br /> W PLOT PLAN ON REVERSE SIDE] <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> `� <br /> APPLICATION ACCEPTED BY 4DATE ,P/a -.7-? <br /> ADDITIONAL COMMENTS: <br /> PHASE II/PKM OSPECTION- PHAS III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE - 2!0- <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />