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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: V 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. V) <br /> r <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued , l/-75f <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 /> n <br /> JOB ADDRESS/LOCATIONz- } CENSUS TRACT <br /> Owner's Nares ��,_- ,�'���.�,� f� Phone <br /> Address zZo Cityf <br /> Contractor's Name 2p�-k_&K a License # 760 Phone <br /> 1 <br /> TYPE OF WORK (.Check): NEW WELL-/ / DEEPEN / J RECONDITION /_/ DESTRUCTION /7 <br /> ,I PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT . <br /> Other /_7 ' <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY }J <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER O <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 <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT- / State Work Donee'`-&/ZwaQ.e f <br /> PUMP REPAIR: / / State Work Done *4 .- <br /> JDESTRUCTiO_N OF WELL: We11 Diameter L c -f: �,, ; - Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local HealthlDistrict <br /> and the State of California pertaining to or regulating well construction. .Within FIFTEEN' DAYS <br /> after completion of my work on anew 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 i <br /> information is true to the best of my knowledge and belief. <br /> SIGNED i � �.-� TITLE <br /> `Y y (.D W PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY jel - - DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II G OUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY441 DATE INSPECTION BY DATE / -// `7 <br /> CALL FOR A GROUT NSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br /> lr'uF <br /> ...-'� �� �e!�,� 1."�". ?' !a�€E. �';�a"war, •F�� ?��:f��<. sr.�.�,^.E;�:fr�:�.:.�:�- sk- xr.€ .x; r,� �t_,u;�':�-4_�•�, tts� <br />