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SAN JOAQUIN LOC. L HEALTH DISTRICT <br /> FOR OFFICE USE: 1.601 E. Hazelton Ave.` -Stockton, Calif. <br /> Telephone: (209).'466-6781 <br /> APPLICATION� FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Z6�70�10 <br /> THIS PERMIT EXPIRES .l' YEAR;FROM DATE ISSUED Date Issued )--_6, <br /> (Complete In Triplicate) ' <br /> Application:-is:hereby,made- to the- San.-Joaquin Local Health District fora 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 an Joaquin Local Health District. <br /> JOB ADDRESS/LOCATIO CENSUS TRACT <br /> 4 Phone i <br /> Owner!s Name- C7 <br /> Address :22z'q--_222 rz 77 City. L- �'�'-� �- <br /> Contractor's Name _ _ Q License �� Phone 7 <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN '/ / RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION -4X/ PUMP REPAIR/ / PUMP REPLACEMENT /-7. <br /> " Other, <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> f SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE- OF'WELL_ , CONSTRUCTION SPECIFICATIONS <br /> industrial Cable Tobl• ' Dia: of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic1public .,Driven Gauge of Casing <br /> Irrigation -:Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of- Grout _ - <br /> '� <br /> OtherOther Information'". ' - ..} . .. . <br /> PUMP INSTELATION 'Contractor, <br /> Types of PU"P y= % w7 H.P. . <br /> T` .. <br /> *I'UMP REPLACEMENT: / / [State-workDone <br /> '+ 'PUMP REPAIR: /�./ .State Work Done <br /> ,DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure . <br /> + !I hereby agree toM1complyywith 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 . strict <br /> } ;;WELL DRILLERS REPORT j of- the4iaell and-no-tify`7rhem before putting the.,.well in use. The above <br /> 'information is true to the best of my knowledge and belief. <br /> TITLE <br /> S I GNED <br /> j. „ (DRAW PLOT PLAN ON .REVERSE SIDE). <br /> :4 ✓got DEP TMENT USE ONLY <br /> PHASE I d i <br /> APPLICATI N-ACChRiZED 'BY ; IiJILSON DATE <br /> ADDITIONAL COMMENTS <br /> PHASE II GROUT, INSPECTION P I NAL INSPECTION <br /> ;:INSPECTION BY DATE INSPECTION BFGTIoN. <br /> DATE Or- <br /> + CALL FOR A GROUT INSPECTION PRIOR.TO GROUTING AND FINAL INS <br /> - 4/72 IMM. <br /> E H 1426 <br />