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s -- <br /> I SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: .(209) 466-6781 <br /> PLICATION FOR WELL, CONSTRUCTION OR PUMP PERMIT Permit No. <br /> - rots <br /> THIS PERMIT .EXPIRES 1 YEAR FROM DATE ISSUED <br /> JJ`C Date Issued <br /> A (Complete In Triplicate) Z y <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> and/or install the worst 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 <br /> CENSUS TRACT 'O®( -p90-//, <br /> Owner's' Names ' <br /> Phone 'S` 7� <br /> Address <br /> City 1:4--tom. C-0-44,11 <br /> Contractor's Name <br /> - License #.2Za3cs Phone <br /> k TYPE OF WORK (Check) NEW WELL DEEPEN / RECONDITION DESTRUCTION /amu <br /> PUMP INSTALLATION IX/ PUMP REPAIR I I PUMP REPLACEMENT /_ <br /> Other / / _„_ <br /> f <br /> DISTANCE TO NEAREST: SEPTIC TANKj <br /> S" SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> _ Industrial k Cable Tool Dia, of Well Excavation lar. <br /> Domestic/private k Drilled Dia, of Well Casing <br /> Domestic/public fi I Driven Gauge of Casing <br /> Irrigation i _ Gravel Pack Depth of Grout Seal 3- <br /> Other k Rotary 7 <br /> - — � y Type of Grout --- <br /> Other Other Information -- <br /> . 1 <br /> PUMP INSTALLATION: Contra Itor oe43 <br /> ^ <br /> Type of Pump b S3 6 <br /> H.P. <br /> -1-----._ <br /> PUMP REPLACEMENT- State Work Done -. . <br />-PUMP- REPAIR: .� / / S.tate:,Work-Done. <br />,DESTRUCTION OF WELL: Well Diameter 2� { <br /> Describe>Material and Procedure -Approximate Depth <br /> a <br /> I hereby agree to comply with 411 laws and regulations of the San Joaquin Local Health District <br /> and the State -of California pertaining to or regulating well construction. Within FIFTEEN <br /> after completion of my work onkDAYS <br /> 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 belief. <br /> SIGNED ,2 E , = 1 <br /> _(D i W PLOT. ON REVERSE SIDE <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: - <br /> DATE <br /> PHAS II GROUT I PECTION , PHAS III/FINAL INSPECTION <br /> INSPECTION BY DATE ,. Z INSPECTION BY <br /> DATE "f�- '7 <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 <br /> 7/72 1M <br />