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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> r <br /> Telephone : (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. a <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is,hereby. made t� 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 0U_ CENSUS TRACT 7 <br /> Owner's Name Ca/g o _r_ ,A _0 !2 T - -- - Phone 3 <br /> Address cZL300 f+ ? City , ,G A P,¢,.7 L4 <br /> �-. <br /> Contractor's Name License #2L5ZZG,L-- Phone Lj(,r� <br /> TYPE OF WORK (Check) : NEW WELL /7 DEEPEN / / RECONDITION YT T?ESTRUCTIQN /_T <br /> AL - - � <br /> PUMP INSTLATION REPAIR / / PUMP REPLACEMENT L <br /> Other /_7 -- <br /> DISTANCE TO NEAREST: SEPTIC TANKfy 0 SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHERr <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool <br /> Dia of Well Excavation <br /> _ Domestic/private Drilled Dia.° of Well Casing z <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout P <br /> Other Other Information 5 <br /> - F <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump AV_�e_ H.P•. 3 - <br /> PUMP REPLACEMENT: State Work Done <br /> y <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. belief10 1-0 <br /> SIGNED c �%C' ���`� TLE <br /> (DRA OT PM ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLYT <br /> ' PHASE I <br /> APPLICATION ACCEPTED BY DATE lo-'7111 7� <br /> ADDITIONAL`COMMENTS: <br /> PHASE II GROUT INSPECTIONPHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE 1INSPECTION BY - DATE Z3X <br /> CALL FOP, A GROUT INSPECTION .PRIOR TO GROU'T'ING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />