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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: ` / 1601 E. Hazelton Ave. , Stockton, Calif. <br /> All, Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Z3.- 8.3/J <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued - 2.2-7--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 apd the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION / Gf�ST/�l� . CENSUS TRACT <br /> Owner's Name Fee ��/.'l� /�'/�(/� Phone 71133- <br /> Address N:30 M&&gk HUe, City y � <br /> Contractor's Name ,Uj�-� �_ � j,_i j p �it1t". License # Phone ! <br /> TYPE OF WORK (Check) : NEW WELL /DEEPEN /-7 RECONDITION /-7 DESTRUCTION /-7 <br /> AL <br /> PUMP INSTLATION /—/ PUMP REPAIR /—/ PUMP REPLACEMENT /-7 <br /> Other / / r <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> a <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS %A <br /> Industrial Cable Tool Dia. of Well Excavation �.4L <br /> Domestic/private Drilled Dia. of Well Casing .r <br /> Domestic/public Driven Gauge of Casing " <br /> I/ Irrigation Li- Gravel Pack Depth of Grout Seal <br /> Other _L-- Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor - ';ole. -- <br /> Type of Pump ,j 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 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 /> (DRA LOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY � DATE °� 'Z7 3 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III7FFI-NAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY�,,r � DATE�,�- <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />