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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. _av <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued3 <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 /> i County Ordinance No. I8 2 and the Rule and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION /�g7y <br /> CENSUS TRACT <br /> Owner's Name S e� �' �� f Y 1Zo -- <br />' <br /> Phone �� <br /> Address <br /> City � C J <br /> Contractor's NameJ . � 1 <br /> ti ..- =License �� 7�a 7 G�ho e _ � o <br /> 3 <br /> TYPE OF WORK (Check.) : NEW WELL /? DEEPEN / / RECONDITION /? DESTRUCTION /_7PUMPAL <br /> . INSTLATION PUMP REPAIR /—/ -PUMP REPLACEMENT <br /> C,, .Other --- <br /> DISTANCE TO NEAREST: " 'SEPTIC' TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT— <br /> OTHER <br /> INTENDED USE TYPE OF WELLIOY <br /> Industrial Y CONSTRUCTN SPECIFICATIONS <br /> ---- Cable Tool `-bia. of Well Excavatioin <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public _ Driven Gauge of Casing <br /> Irrigation > i Gravel Pack Depth of Grout Seal <br /> Other T_ Rotary Type of Grout , <br /> Other Other Information <br /> PUMP INSTALLATION.- Contractor' <br /> Type of Pump a Y. H.P. <br /> PUMP REPLACEMENT Ryan mum �,� P� ,� c� iP p�.�gcCr <br /> / State Work Done d <br />-PUMP 4REPAIR-:----/7_ .. . <br /> /'�Sta-te'WorknDone— __ �.:�_ -� �.�-..�. .� <br /> DESTRUCTION OF WELL: Well Diameter <br /> ' --- � j -• Approximate Depth <br /> Describe Material and Procedure ; p <br /> I hereby agree-'ro comply with all laws and regulations of the San Joaquin Local Health District <br /> and the`State of -California pertaining -to "or-regulatingtwell construction. Within FIFTEEN DAYS <br /> after' co'mplet�ion of "* work, on a new well, I will furnish the San Joaquin Local health District <br /> WELL DRILLERS REPORT of,fhe-weli- and 'notify them before putting the well in use. The above ct a <br /> information is true o th best of my knowledge and belief. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE I DEPA <br /> FOR LRT IT USE ONLY <br /> APPLICATION ACCEPTED BY t} DATE <br /> ADDITIONAL COMMENTS: :3 <br /> PHASE II GROUT INSPECTION PHASE IIII/FIUL INSPECTION <br /> INSPECTION BY - "DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTIONkPRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 <br /> 7/72 1M <br />