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.f <br /> �,AN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> \PPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.,%'-�- !;' 4-.� <br /> 4 <br /> THIS) PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued.i <br /> 3 (Complete In Triplicate) <br /> Application is hereby ride to the San Joaquin Local Health District for a permit to construct <br /> and/or install the work horcin described. This application is made in compliance with San J.:�;uin <br /> County Ordinance No. 1862 nod gthe Rules and Re1gul�atilons of the San Joaquin Local Health Distract. <br /> JOB ADDRESS/LOCATION R CENSUS TRAC'try 7S <br /> Owner's Name � �Z ��� Phone _a -- <br /> Address 1 4- 4 ST City <br /> Contractor's Name��a -V h icense f ,;01147hone <br /> TYPE OF WORK (Check): NEW fai:i 1, DEf:PEN RECONDITION /7 DESTRUCTION /-7 <br /> PUMP INsTAL TION L7 PUM' REPAIR /-7—PUMP REPLACEMENT /7 <br /> 0thf r / 7 -- <br /> r DISTANCE TO Ni'ARCST: ST—M-1 c' TANK SEM LINES PIT PRIVY <br />` SEWA(,L DISPOSAL FIELD CESSPOOL/SEE;PAGE PIT l�� OTHER � <br /> INTENDED USE TYPES OF WELL CONSTRUCTION SPECT IC IONS <br /> Industrial K Cable Tool Din. of Well Excavation <br /> Domestic/privnt,� _ Drilled Din. of Well Casing $ <br /> Domestic/public Y Driven Gauge of Casing 1244 • <br /> _ Irrigation _ ^ Gravel Pack Depth of Grout Seal C <br /> Other Rotary Type of Grout 07. _ <br /> t . Other Other Information TAAZ ; <br />: Ve <br /> PUMP INSTALLATION: Cw�trnctur""'C'R - <br /> f TypoAt <br /> of Pump � ���� H.P. <br /> y; PUMP REPLACEW.NT: / 1 5tncc Work Done <br /> PUMP REPAIR: / 1 t:oto Work Done <br /> ,3P )ESTRUCTION OF WELL: W,,I l 1)in"v,ter Approximate Depth <br /> 11,c- Material and Procedure _ <br /> I hereby agree to comply with nil laws and regulations of the San Joaquin Local Health District <br /> and the Slate of e;nliforeiin p-rt,iining to or regulating well construction. Within FIFTEEN DAPS <br /> after completion of my work -1 n new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of thc well and notify them before putting the well in use. The above <br /> information is truee• tn thr :`teat of my knuwled and b ief. <br /> Atj <br /> SIGNED 1 c�-i� - 7Jt+ulr _.�.'� � TLE <br /> r� RAW PLOT P N REVERSE SIDE <br /> FOR DE TMENT USE ONLY <br /> : PHASE I <br /> APPLICATION ACCF;FTED BY ` ` V i,'� DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY _�---- (DATE ' 7- ?. INSPECTION BY DATE __ <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. iF <br /> E H 1426 <br /> 7/72 1M <br /> v <br /> wpp <br />