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3WN JOAQUIN LOCAL HEALTH DISTRICT ' <br /> FOR OFFIC USE: 1601 E. Hazelton Ave. , Stockton, Calif . <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 71 / <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 Ng !�/du cy� 1/ �<./.� lvrrr®r D+Q ��Cr CENSUS TRACT 2o/_ ,9V_�3 <br /> Owner's Name 1-JL Ly-,t,cm /I u_r Phone <br /> Address !_ h n / C r0 'n city Sid <br /> Contractor's Name � � 09`/ a+_/i, 1_�� License U /f3),kr'Phone 1161--26 <br /> TYPE OF WORK (Check): NEW WELL / / DEEPEN /_7 RECONDITION /_7 DESTRUCTION /_ <br /> PUMP INSTALLATION / / PUMP REPAIR Z�/ PUMP REPLACEMENT /-T <br /> Other <br /> J <br /> DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES PIT PRIVY W <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER i <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <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 �C'yfj �r H.P. / <br /> N <br /> PUMP REPLACEMENT: / / State Work Done `iii O/L{ *e?,Z 1,440 <br /> PUMP REPAIR: / / State Work Done <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 is true to the best of my knowledge-and belief. <br /> SIGNED TLE <br /> (MW P T PLAN ON ERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY �JL! DATE <br /> ADDITIONAL COMMENTS: T -~y <br /> P II GROUT INSPECTION PHAS I FINAL INSPECTION <br /> INSPECTION BY / jDATE ��-� INSPECTION BY DATE `l/ <br /> ,r <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M (� <br />