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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> IFOX-OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. - - <br /> TINS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued S.;/ <br /> (Complete In Triplicate) <br /> f Application is hereby made '�o 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 abet the Rules and Regulations of the San Joaquin Local. Health District. <br /> .TOB ADDRESS/LOCATION,4/-?Qp ,1�7751151�,' r � r CENSUS TRACT <br /> Owner's NameCiib�et7 ,�, ^� Phone a' 7 <br /> Address g,,lp . . City zi;;:ti <br /> Contractor's Name License # Phone :.fZr---4V <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN/ / RECONDITION_/ / DESTRUCTION /_7 <br /> PUMP INSTALLATION J J PUNip REPAIR / /_PUMP REPLACEMENT fi�?' . <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 (u <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of. Well Casing " <br /> Domestic/public Driven Gauge o£ Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> r Type of Pump H.P. <br /> PUMP REPLACEMENT: State Work Done,25;Tx-T,, � <br /> PUMP 'REPAIR: J J State Work Done <br /> DFgTRUCTION-OF WELL: Well Diameter _ Approximate Depth <br /> - - --- - Describe Material. and Procedure � T <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> r 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 .fur�tish the San Joaquin Local Health District <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 k 'ledge and belief. '- <br /> SIGNED TITLE �.o/�/.Q -� .G't cIle, <br /> 1 (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I g. <br /> APPLICATION ACCEPTED .BY Y, DATE <br /> ADDITIONAL CONIDIENTS: <br /> PHASE II GROUTINSPECTION P E FINAL INSPECTION r <br /> INSPECTION BY ! DATE INSPECTION BYDATYN <br /> E <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. (.` <br /> ' ENI 1M <br /> 1+26 5/73 <br />