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.fs <br /> 9 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , :Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7S _2eoP , <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued L/7-1 <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 / Jl' -- �,.� CENSUS TRACT 24f-30O <br /> Owner's Name ry � .�� �� - _�����'� Phone�r�` � _75� <br /> Address / � _ /� —,rr � - '! City <br /> Contractor's Name g. �-�; cF�' j Q License # 7 Phone /y✓'711 <br /> TYPE OF WORK (Check): NEW WELL / / DEEPEN /_/ RECONDITION /_7 DESTRUCTION /_7 4 <br /> PUMP INSTALLATIONS / ,/� 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 C � <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS p { <br /> Industrial Cable Tool Dia, of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing t <br /> Domestic/public Driven Gauge of Casing ^' <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information ` <br /> PUMP INSTALLATION., Contractor � �r <br /> Type H.P. <br /> .....__. <br /> yp of Pum, <br /> p .P. (Tl <br /> PUMP REPLACEMENT: / / State Work Done {. ✓ �. 4� % �f -' -rte ! G! e�-d , <br /> PUMP REPAIR: / / State Work 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 wok on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of th . well and notify them before putting the well in use. The above <br /> informatio ' is true tom e �17/_ <br /> of my knowledge and belief. <br /> SIGNED '„� �s � _ TITLE '' <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: ' <br /> PHASE II GROM INSPECTION PH#SF.N4Ij4FINAL INSPE TION <br />' INSPECTION BY DATE INSPECTION BY DATE <br /> r ,- CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSP ON. <br />.4 ' <br /> E H 1426 7/72 1M <br />