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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 /> I APPS ATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �Z_� 63 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date issued 9-13-7Ti <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 18_62 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION /a,C ,;ENSUS TRACT 0(5-ZLO-(�0 <br /> Owner's Name We BODCe ,'� / '' C Phone <br /> Address PA Rd K ,1 ..,_....._., OW 1301-15K_ CXY ZA, City L0121 <br /> Contractor's Name _ �� /?/r W I'rl Z It C License # _1�Phone <br /> TYPE OF WORK (Check): NEW WELL ffr DEEPEN /_/ RECONDITION /_7 DESTRUCTION /_ <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other 4 IIV l <br /> J N <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD ti CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS { <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other TD _ Rotary Type of Grout <br /> Other 0 <br /> j Cher Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump r H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br />' PUMP REPAIR: / / State Work Done <br /> .RESTRUCTION OF WELL: Well Diameter- Approximate Depth <br /> t 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 twhe 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 />` <br /> information is true to the best of my knowledge and belief. <br /> SIGNED TITLE ,( /�,Q (�, �/j7 <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I r <br /> APPLICATION ACCEPTED BY DATEr--. �— <br /> ADDITIONAL COMMENTS: <br /> PHASE 11 GROUT INSPECTION PHAS III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY L(b DATE / 2•//� <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H.,1426 7/72 1M <br />