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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. '?Z' z <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 1 Z 7 -7 <br /> (Complete In Triplicate) <br /> Application is herdpy 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 _ 1/Li`l'✓' _�'t., ,, "yam CENSUS TRACT <br /> Owner's Name M/p ram_ Phone <br /> Address - T / SY 'Y _ a !.t i� City �dcl ?�� <br /> - <br /> Contractor's Name 74,t?PAI License til&2),,jL--Thon4&-k-74 ;7.6 <br /> TYPE OF WORK (Check): NEW WELL ' DEEPEN /_7 RECONDITION /7 DESTRUCTION /7 <br /> PUMP INSTAL= 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 <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal N <br /> Other Rotary Type of Grout <br /> 3 <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor S74*-� at* <br /> Type of Pump S ,! H.P. / <br /> PUMP REPLACEMENT: / / State Work Done <br /> Pwe State Work Done 2W,pg±jUp *4oIL d/ t ted -^,1�.�fir!✓ sM 012k) <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 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 /> SIGNED TLE r�rf' <br /> (D OT AN ON RE SE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY p� DATE OL__ INSPECTION BY DATE p <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPE ON. <br /> E H 1426 7/72 1M cton <br />