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SAN JOAQUIN LOCAL HEALTH DISTRICT F �_ <br /> FOR OFFICE USE: 601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6781' <br /> PLICATION FOR WELL CONSTRUCTION OR PUMZ <br /> P PERMIT Permit No. 7 -q3 <br /> t. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ; Date Issued _6_2_q_-7b- <br /> (Complete <br /> 6-zq_-7v(Complete In Triplicate) <br /> Application is heeb 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 /> k County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION Isla / - �,,«,� CENSUS TRACT <br /> Owner's Name �. ra_ ..... Phone 22- <br /> Address 1 ?u _ _ n.r,e_J _,. City <br />` Contractor's Name _ [�"� � .,,, r�,l„ License # ,x,373 Phone <br /> TYPE OF WORK (Check) : NEW WELL '/ / DEEPEN '/_7 RECONDITION /—T DESTRUCTION /`7 <br /> PUMP INSTALLATION REPAIR -/ / PUMP REPLACEMENT A-7 <br /> Other ] / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> E <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER f <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS `J ' <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> � I <br /> Domestic/public Driven Gauge `of Casing ! <br /> Irrigation Gravel Pack Depth of Grout_ Seal ' <br /> Other Rotary Type of Groui a <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> . I <br /> PUMP REPLACEMENT: / S tate Work Done , I I 11_7; 'l h1ali <br /> PUMP REPAIR: = - %- / -State Work Done r •[� <br /> ,PESTRUCTION 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 Ad <br /> (DRAW PLO LAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE fj <br /> r ADDITIONAL COMMENTS: z <br /> PHASE, II GROUT INSPECTION PHASE III FINAL INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY DATE ' 7 <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTI . <br /> E H 1426 4/72 1M <br />