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% SAN JOAQUIN L GAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: ,(209) 466-6781 <br /> APPLICATION-VOR -WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 6 <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 /> i <br /> JOB ADDRESS/LOCATION & jL 7-,qv/O.R RIO(, $ 3D CENSUS TRACT <br /> Owner's Name , - 6 {_ Phone , <br /> Addressr, City <br /> Contractor's Name D y,�5 �- Se- JI-P.- - License # 4Z AIIIS�'Phone ' -tao <br />-TYPE.-OFiWORK-(Check-),:—NEW�WELL-/ ,;DEEP-EN/:/._-RECONDI-T-IONS/ —DESTRUCT.—ION—/?..� <br /> PUMP INSTALLATION / / PUMP .REPAIR- / / PUMP, REPLACEMENT ��. <br /> r 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 (n, <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 /> - - - - S <br /> Other Other Information <br /> i <br /> PUMP INSTALLATION: ContractorDa M f r "f ,r. <br /> LIce— <br /> Type of PumpH.P. �c <br /> PUMP REPLACEMENT: / J State Work Done <br /> PUMP REPAIR: State Work .Done- <br /> JDESTRUCTION. .OF WELL.,:.,,.; .Well Diameter Approximate Depth"` 1' <br /> I4 <br /> " R 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 °co"mpletionYof 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 TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY146LAA� DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE _ r INSPECTION BY DATE -:T2 <br /> CALL FOR-A-GROUT INSPECTION PRIOR TO GROMA_ NG -4ND FINAL INSPECTION. <br /> E.H­f4_26 �` 7/72 1M <br />