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c N JOAQUIN LOCAL HEALTH DISTRIC <br /> FOR OFFICE USE: 16bw,E. Hazelton Ave. , Stockton, Cat-ff. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued g'. -73 <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 Joaquil <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 49, V Zo e sd CENSUS TRACT 5�� <br /> ' 'ee � <br /> Owner's Name g <br /> �.e�p , �`� Phone <br /> �'27 <br /> Address , b - City <br /> Contractor's Name ,J ( :-,j License a`Z Phone <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN /% RECONDITION /7 DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR _W PUMP REPLACEMENT /7 <br /> Other /—/ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER C <br /> �� q <br /> INTENDED USE V TYPE OF WELL CONSTRUCTION SPECIFICATIONS �t <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 /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump t H.P. p <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: State Work Donec2'eg n u L—oS <br /> ,DESTRUCTION 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 /> information iq true to the best of my knowledge and belief. / <br /> SIGNED Q�/� � -_-W�~ � TITLE '7[e-nj9-/ <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY �? DATE 70 <br /> ADDITIONAL COMMENTS: ` <br /> PHASE II GROUT INSPECTION PHASE II / gINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. W- <br /> E H 1426 7/72 1M <br />