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SAN JOAQUIN LOCAL HEALTH DISTRICTc4L <br /> 3 FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : ' (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.7zR �5 w <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date'Issue'd -7)/ <br /> i <br /> (Complete In Triplicate) <br /> E 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 /> JOB ADDRESS/LOCATION "' � 6)_et-}'WS 46 CENSUS TRACT <br /> Owner's Name // Al l? zod Phone <br /> C Address 1/4� IV L/� - �� - CityDCke�j <br /> Contractor's Name C_ A A ]! &A t& yW7, CO, ^T License # 440,E Phone ".?--�,7 <br /> s <br /> 1 <br /> TYPE OF WORK (Check) : NEW WELL _/ DEEPEN / / RECONDITION /� DESTRUCTION /� <br /> PUMPIINSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /? <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD 571-9` CESSPOOL/SEEPAGE 'PIT OTHER <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 �Gau'g+e'of Casing /2 <br /> -, Other <br /> Gravel Pack� Dephof Grout Seal <br /> Other Rotarq" Type of GroutL( � <br /> Other _Other Information <br /> PUMP INSTALLATION: Contractor + �4 <br /> Type of Pump - H.P. <br /> f <br /> PUMP REPLACEMENT-: 1 / / State Work Done ,_ -- <br /> PUMP REPAIR: / / State Work-Done <br /> ,DESTRUCTION OF WELL: Well Diameter ` ., Approximate Depth <br /> rr Describe Material and Procedures <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> k and the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> jj 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 /> informatio is true to the best of my knowledge and belief.. <br /> ` SIGNED !! TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE/e//9/�71 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT 11#9PECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 f vn 3,Qc �a�. . .�s'� ����x-7/72 1M <br />