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_ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 071-OF 710E USL": .1601 E. Hazelton Ave. , Stockton, Calif. 1 <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT hermit No. 73--S3 p <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued _7-73 <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 Regul tions of the San Joaquin Local Health District. <br /> 3-7 L( S: .$E.s-t—"3 13a6 K <br /> .FOB ADDRESS/LOCATION 1p 4-a 5 CENSUS TRACT <br /> Owner's Named Phone 46ef 043 <br /> Address S' � u..�-vs _ City,' _ <br /> Contractor's Name License # 76p7&/ Phone ,�t,64 rt2.:?rr <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN'/-/ RECONDITION DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /- <br /> Other <br /> _ � I <br /> DISTANCE TO NEAREST: SEPTIC TAiINK /,r-p` SEWER LINES PIT PRIVY <br /> . SE14AGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT. OTHER � <br /> ' INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial , ,;� Cable Tool Dia. of Well Excavation <br /> 1C Domestic/privateDrilled Dia. of Well Casing } <br /> Domestic/public x ' Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other {. Rotary Type of Grout <br /> Other Other Information ' <br /> k <br /> } <br /> PUMP INSTALLATION: Contractor <br /> } <br /> Type of Pump H.P. 3 <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP 'REPAIR: " a <br /> / / State,Work Dune <br /> ,DFsTRUCTION 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. , J <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 /> SIGNEDys.�t^-�L�t TITLE <br /> (DRAW'PLOT IFLAN UN REVERSE SIDE) i <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED .BY ®v' ' DATE f1217 3 <br /> ADDITIONAL COUNTS: tzl-c . <br /> IGR <br /> II GROUT NSPECTI N PHA III/FINAL INSPECTIO19 <br /> INSPECTION BY DATE '� INSPECTION BY DATE ` <br /> CALL FOR AT.INSPECTION PRI R TO GROUTING AND FINAL INSPEC ON. r <br /> ti E H 1426 �/731M i <br />