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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR.OFFICfE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATP N FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. X71 UJ <br /> i 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 peimit 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 2SS 2 L CENSUS TRACT <br /> Owner's Name 17AN I EL___. t� Phone <br /> Address AID 1-/LF_F, _ city ^ <br /> ~ <br /> Contractor's Name `License # <br /> � - - - <br /> TYPE OF WORK (Check): NEW`WELL DEEPEN /? RECONDITION /_7 DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK7u, SEWER TUNES �Q PIT PRIVY ICV. C <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT j - OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial' Cable Tool Dia. of Well Excavation <br /> --dt:-15omestic/private Drilled Dia. of Well CasingQ _ � <br /> Domestic/public Driven Gauge- of Casing - 13- <br /> Irrigation <br /> Irrigation Gravel Pack Depth .of Grout Seal j%0 <br /> Other -�Rotary Type of Grout <br /> _.w Other -Other -Information' <br /> PUMP INSTALLATION Contractor, (� <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State -Work Done <br /> PUMP REPAIR: /% State Woik-Done ' - <br /> ,.RESTRUCTION"OF WELL: Well Diameter 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 /> informati n is true to the best-of -my knowledge--and belief: - <br /> SIGNED TITLE -- <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FO P T USE ONLY <br /> PHASE-I a _ <br /> APPLICATION ACCEPT !_ e Y DATE 72— <br /> =09W-1r10-_ <br /> ADDITIONAL CO _ _ ._ .. <br /> P I UT INSPECT ONPH#W.1IjT1jAFNAL INSPECTION <br /> INSPECTION BY DATE -- INSPECTI DATE - -7 3 <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />