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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE U E: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> �2 t 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 /1 7,- <br /> (Complete <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 ADDRESS/LOCATION ---Z6 2 11 7 S LS T Oh� CENSUS TRACT <br /> Owner's Name -i Q T 1.491 iAI V <br /> — Phone <br /> Address 2ZY3 7 ✓.01 ,41 Eeef l-) /`i'P city = <br /> 11116171-CA <br /> Contractor's Name "_�;s I?A- W1 f i -1 /: C1 0 f l'' frG3 License # 76 L C`2 Phone <br /> TYPE OF WORK (Check): NEW WELL ,/ DEEPEN /_/ RECONDITION /-7 DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / 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 �/L1 <br /> _ Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing f <br /> Irrigation Gravel Pack Depth of Grout Seal 6-6; <br /> Other Rotary Type of Grout C,4'1ti11 Al T <br /> Other Other Information <br /> C <br /> PUMP INSTALLATION: Contractor } <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Wgrk. 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 <br /> (DRAW PLOT PLAN ON REVERTITLE SE SIDE—r <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY �l� �D DATE <br /> ADDITIONAL COMMENTS: T <br /> PHASE II ' OUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY r DATE ��-(3- 7Z-----=?ECTION BY DATE _Z� <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M C,612r <br />