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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. 3- -14 U/ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued �,-IL 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 /> b <br /> JOB ADDRESSZLOCA ION <br /> O CENSUS TRACT cS I <br /> Owner's Name74. Phone <br /> Address c; o City <br /> Contractor's Namex `.r. ` /" /zcense #Z6�2. Phoney f�17 <br /> TYPE OF WORK (Check): NEW WELL & DEEPEN /-7 RECONDITION /_/ DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /- <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK Q EWER 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 t9"' !� <br /> Domestic/private Drilled Dia. of Well Casing // /� <br /> Domestic/public Driven Gauge of Casing , Cl ca : <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout q -`4cht 4,21.t. : <br /> Other Other Information /4 <br /> PUMP INSTALLATION: Contractor �rC <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State 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 REPO of the well and notify them before putting the well in use. The above <br /> information is a to the best of knowledge and belief.. 0DELVS PUn_^ r.-,P mo,rQr,si;tv, <br /> 796 Del P--,o 131vd. <br /> �acrar.:en,q, (;x; p:Dix 9581! <br /> SIGNED Z�_nTITLE �A��/^ <br /> LUKAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE j'-,t,/-7.t INSPECTION BY � DATE 7-/P -;?J <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. LU-011 <br /> E H 1426 7/72 1M <br />