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t I f, 5 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE E: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6781 <br /> 11 V /APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Z 3 7 <br /> J�. <br /> I THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -15/7 Z- <br /> C (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 workfherein described. This application is trade 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. 4�i. l F ¢}a 5oJ7b/��=/ilt /�i !�X, "` CENSUS TRACT <br /> Owner tls Name - �_ s l ,�fy t_/ _ Phone -3 6 3.3 <br /> Address 7 7 I 1?L-'S c� v City <br /> Contrdctor's Name �:e� f� g� License Phone <br /> h <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN /-7 RECONDITION /-7� DESTRUCTION 1-7 <br /> PUMP INSTALLATION />(/ PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other <br /> ,} 0. <br /> DISTANCE TO NEAREST: SEPTIC TANK �_ SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER It1 <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 /> ryIrrigation Gravel Pack, Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> I 9� Other Other Information <br /> PUMP INSTALLATION: Contractor -* <br /> Type of Pump H.P <br /> I_ <br /> PUMP REPLACEMENT: /7T State Work Done <br /> EI T <br /> PUMP REPAIR: -Ir. /�S to to Work Done - - - - <br />' .RESTRUCTION OF WELL: Well Diameter --. Approximate Depth <br /> Describe Material and Procedure + <br /> �I <br /> I hereby agree to comply` with all laws and regulations of the San Joaquin Local Health District <br /> .p q <br /> and the State :bf California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> after completion of tay work on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT ofj�ihe 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 /> SIGNED3 -4_ ��- '`7 --• `-«'l ' TLE <br /> I�. <br /> (DRAW PLOT -P N REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY '• DATE /OC/7�2— <br /> ADDITIONAL COMMENTS <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY III DATE INSPECTION BY ff. DATE //-,;Lo <br /> CALL FOR A GROUT INSPECTION PRIOR'TO GROUTING AND FINAL INSPECTION. <br /> E 9' .1426 ! ' 7/72 1M <br />