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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. l <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 3-34P <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued. <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 /> JOB ADDRESS LOCATION 1A q,-145- N--746,_ R U CEI4SUS TRACT S ! <br /> Owner's Names -- ] / Phone 3/-�!I 2 <br /> Address / Z y"t3 / V lariL City <br /> Contractor's Name �.�� J�/. if-fes '` License #lg_q 4 Phone '74,L1o.5`2. <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN / j RECONDITION /7 DESTRUCTION /_7 .� <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT /� <br /> Other /7 j <br /> DISTANCE TO NEAREST: SEPTIC TANK 96` SEWER LINES PIT 'PRIVY .11 ; <br /> SEWAGE DISPOSAL FIELD .CESSPOOL/SEEPAGE PIT— >. ,OTHER <br /> __ <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS . <br /> Industrial Cable Tool Dia, of Well Excavation 12- <br /> Domestic/private <br /> Z <br /> Domestic/private Drilled Dia. of Well Casings <br /> Domestic/public Driven Gauge of Casing /21 <br /> - Irrigation _ .F -Gravel--Pack- Depth of Grout Seal D ` <br /> Other Rotary __. Type of Grout I` <br /> Other other Information <br /> c .ar - <br /> PUMP. INSTALLATION: Contractor <br /> Type of Pump 2 H.P. <br /> I <br /> PUMP REPLACEMENT: ] / state Work Done <br /> R r � <br /> PUMP REPAIR.* /% State Work Done <br /> ,DESTRUCTION OF WELL.' Well Diameter Approximate Depth i <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 TITLEcGL <br /> RAW PLO PLAN ON REVERSE SIDE. <br /> FOR DLTARTMENT USE ONLY <br /> t PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASEJI GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BYDATE '7:3 INSPECTION BY DATE,//-E-Z_3 <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />