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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 /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.T3 s�o Cv <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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 /pal CENSUS TRACT <br /> Owner's 11ame p l-A V M &IV Phone 4 7�� <br /> Address _ e a L. a js C i t Y 1 . el 1-i <br /> Contractor's Name License #,2 ZA L Phone ej <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN /-7 RECONDITION /-7 DESTRUCTION /-7 <br /> PUMP INSTALLATION / 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 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation fa" <br /> Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing, d <br /> Irrigation Gravel Pack Depth of Grout Seal y U <br /> Other - j� Rotary Type of Grout <br /> Other Other Information <br /> S <br /> PUMP INSTALLATION: Contractor ate` Z7 <br /> Type of Pump a -CH.P. - <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done j <br /> ,2ESTRUCTION 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 /> SIGNEDe�®G� .d.s�.rl, c� � r- QTc F ITLE <br /> (DRA PLOT FtAN ON REVERSE SIDE <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY C., DATE f - 4 73 <br /> ADDITIONAL COMMENTS: ¢�/ <br /> PHASE II GAPUT INSPE TIO PHAW III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY , DATE <br /> CALL FOR A GR UT INSPECTION PRIG TO GROUTING AND FINAL INSPECT ON. <br /> E H 1426 7/72 1M <br />