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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WkLL CONSTkUCTION OR PUMP PERMIT Permit No. 73- 3Vek) <br /> 73-.79-6 p <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -/7 4-73 <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 Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin L?rW Health District. <br /> JOB /LOCATION ay CENSUS TRACT - <br /> Owner's Name c Flo Phone <br /> c, <br /> F Address City AP,"2992n -- <br /> Contractor's Name License Phone <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN /" RECONDITION /� DESTRUCTION <br /> PUMP INSTLATION / UMP REPAIR / / PUMP REPLAC <br /> ALEMENT <br /> Other /-7 ► <br /> DISTANCE TO NEAREST: . SEPTIC TANK SE R.LINES �p�PIT PRIVY <br /> SEWAGE DISPOSAL FIELD LJSEEPAGE PIT -OTHER <br /> INTENDED USE TYPE OF,WELL CONSTRUCTION SPECIFICATIONS <br /> F <br /> Industrial" `' -.,. a :Cable ,Tool =+Dia. ' of- Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing ,A <br /> Domestic/public Driven Gauge of Casing j <br /> Irrigation Gravel Pack Depth of Grout Seal Y C <br /> Other Rotary Type of Grout <br /> Other, Other Information <br /> PUMP ' INSTALLATION-. Contractor, /� X55 i <br /> Type of Pump ` H.P. <br /> t PUMP REPLACEMENT: /, / State Work Done <br /> PUMP REPAIR: j State Work Done g'a C,440 110c <br /> i ,DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> t Describe Material ana Procedure "r <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 Heaith ,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 /> k SIGNED <br /> + (DRAW PLOT PLAN ON REVERSE SIDE) <br /> ff FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> r APPLICATION ACCEPTED BY DATE <br /> j ADDITIONAL COMMENTS: \'11- 7 <br /> -P �II ROUT-INSPECTI N^ " - - - '-PHAS " I/FINAL' INSPECTIO <br /> INSPECTION BY. DATE YZa INSPECTION BY DATE <br /> CALL FOR A GR INSPECTION PRIG TO GROUTING AND FINAL INSPECT N. Af <br /> E H 1426 7/72 1M <br />