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fly SAN JOAQUIN LOCAL HEALTH DISTRICT \ <br /> FOR OFFICE USE: 160^?. Hazelton Ave. , Stockton, Ca_ <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �3 9�p <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 Joaquii <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> I <br /> JOB ADDRESS/LOCATION .� n iytl/� l✓u� o1C�4ur)atDA ]21 % 1,,61, Fi rr CENSUS TRACT <br /> Jwner's Name �' 1 <br /> R•� Phone <br /> Address City f.7�dtlEiC� <br /> :ontractor's Name S7 ert�¢.e � y- � License # <br /> p � <br /> CYPE OF WORK (Check) : NEW WELL / / DEEPEN / / RECONDITION / / DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT / <br /> Other / / — <br /> )ISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> T <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS 'S <br /> Industrial Cable Tool Dia. of Well Excavation <br /> _X Domestic/private Drilled Dia. of Well Casing 5 <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 /> 'UMP INSTALLATION: Contractor Z ;•z� <br /> Type of Pump _ < H.P. <br /> 'UMP REPLACEMENT: State Work Done <br /> 'UMP REPAIR: / / State Work Done <br /> ^ESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> nd the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> iter completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> ELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> nformation is true to the best of my knowledge aki�d belief. <br /> IGNED —� TDt.)cr/qtr /s t -t5 ,sa �/"TITLE <br /> ( PLO PiaN nN u ERSE SIDE) <br /> HALE I DEPARTMENT USE ONLY <br /> eC <br /> PPLICATION ACCEPTED BY DATE <br /> DDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE II/FINAL INSPECTION <br /> NSPECTION BY Jn a — DATE INSPECTION BY DATE �? <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. U* <br /> E H 1426 7/72 1M <br />