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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. 73-85� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ;2-a28-1Zf <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. 1562 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION ` �'`- - ,. -&, E <br /> '12&jaZ &1,516Ajey CENSUS TRACT loo -ve <br /> Owner's Name /(, Phone ` <br /> Address f City / A17-6-0V <br /> Contractor's Name License # 1,L3Q <br /> TYPE OF WORK (Check) : NEW WELL /9' DEEPEN /-T RECONDITION /_7 DESTRUCTION /_ - <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other /% <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _ PIT PRIVY <br /> SEWAGE DISPOSAL, FIELD CESSPOOL/SEEPAGE PIT OTUR <br /> -��. �.�..cx�.,cc�,w. /�fZ• /°iLr.�..�,rc /'res" �-ri' <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECI I ATIO S <br /> Industrial Cable Tool Dia. of Well Excavation 1p " <br /> Domestic/private Drilled Dia. of Well Casing &A " - �- <br /> Domestic/public Driven Gauge of Casing T <br /> Irrigation Gravel Pack.- Depth of Grout Seal <br /> Other pe' Rotary Typemof Grout <br /> Other ther Information7VIAL <br /> L f <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: /% State Work Done <br />,)DESTRUCTION OF WELL: Well Diameter _ <br /> .... _,.,_... 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 . er„ ,,r TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY . � ATE <br /> ADDITIONAL COMMENTS: <br /> i PHASE II GROUT INSPECTION � PIRKS i NAL INSPECTIO <br /> INSPECTION BY „ DATE INSPECTION Y / DATE G <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. � <br /> E H 1426 7/72 1M <br /> I <br />