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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> k FOR OFFICE USE: 1601 E. Hazelton'`Ave. , Stockton, Calif. <br /> Telephone : (209) 4666781 -2,3- <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.75-303- c,J <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued6 . <br /> j (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 Joaquii <br /> County Ordinance No. 1862 and the Rules and Regulations oft' the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION $' aev 4TA <br /> p CENSUS TRACT <br /> Owner's Name . ;e v i -- Phone .7 q 'Z p <br /> Address /. S" ��* t EY City 7-160 _01f%' CAS <br /> Contractor's Name 0 7- 'm License #��3� ,�_3 Phone 7,tCi 3 0 s <br /> TYPE OF WORK (Check) : - NEW-WELL DEEPEN /_7 `RECON6IT20N -7- DESTRUCTI6—N /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR /,�(/ PUMP REPLACEMENT /_7 <br /> Other /% -- <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL <br /> CONSTRUCTION SPECIFICATIONS Lr`� <br /> Industrial Cable Tool Dia. of Well Excavation <br /> j Domestic/private Drilled Dia. of Well Casing � <br /> Domestic/public Driven Gauge of Casing p <br /> irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: ContractoryG /,ctc �1—/f bS -741 _ <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Donee <br /> PUMP REPAIR. / State Work Done & <br /> ESTRUCTION OF WELL: Well Diameter Approximate Depth - <br /> Describe Material and Procedure <br /> I hereby .:-agree to comply-with all aw <br /> $ 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 Limit ' t + <br /> TITLE <br /> UZI t.C' <br /> ( 1AW PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION. PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE �� INSPECTION BY DATE _ ,P` <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br />�� E H 1426 7/72 1M <br />