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-LT <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.'d_ <br /> 9, . <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued/p <br /> (Compl.ete .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 N . 1862 and ,the Rules and Regulations of the San Joaquin Local Health District. <br /> a? Z�L _ <br /> o� uG1C .` <br /> JOB ADDRESS/LOCATION IVOR "Tlj/0CENSUS TRACT <br /> Owner's Name w - s x� Phone 46 ij_- <br /> Address .3 "~ I 'MAI <br /> City . S< <br /> Contractor's Name P -T 66S ���'_ -_-- —_-� License #18e45`044 Phone 741'/dS- <br /> TYPE OF WORK (Check) -NEW -WELL / ( DEEPEN /_/ RECONDITION /7 DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /_ <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK 47F ` SEWER LINES PIT PRIVY Z <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial X Cable Too! Dia. of Well Excavation C-0 <br /> - Domestic/private Drilled Dia. of Wel! Casing $" <br /> Domestic/public Driven Gauge of Casing /. a <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> t � <br /> PUMP INSTALLATION: Contractor &�Zl � � i <br /> .----....Type-of Pump - H.P •3 <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> ESTRUCTION OF WELL: Well Diameter 41 Approximate Deptti' <br /> Describe Material and Procedure <br /> 1 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 /> F. SIGNED TITLE �� <br /> RAW PLO LAN ON REVERSE SIDE <br /> i FOR DEPARTMENT USE ONLY <br /> PHASE I DATE,,,-0- <br /> APPLICATION ACCEPTED BY /A 7 7z� <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY . DATE /-e- 73 _ INSPECTION BY ea - _- DATE �•�' -7,3 <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 IM <br />