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a <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ,/ -FOR- OFFICE USE: 1.601 E. Hazelton Ave. ,. Stockton, Calif. <br /> Telephone.: (209) 466-6781 7-2'11/Cv' <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7,,2,-3 9 P <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued /b - - <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 Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Ph <br /> Owner's F-- _ <br /> Owner's Name Y_/h1/�'E1fL ' Y/L <br /> Address - -- pZ,3 - 1 ,�//�s�`' /�' City '"`-A'-'po <br /> Contractor's Name �/E Cbl' _ _ License #��� Phone, <br /> - <br /> dfl Im SIG' 61 _ <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN /_/ RECONDITION /-7 DESTRUCTION <br /> PUMP INSTALLATION�' PUMP REPAIR / I PUMP -REPLACEMENT /-7 { <br /> Other / J <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD 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 Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal ' <br /> Other Rotary Type of Grout Sk <br /> -- _ <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor y <br /> Type of Pump jt-y-- -kC 421 b_ H.P. <br /> PUMP REPLACEMENT: / / State Work Doner/f/ �i�-44 G�77Sfi,fiC� 7�V�LL /{��fl <br /> /AV1fiiVL6,,, MY /H fid W&L <br /> PUMP REPAIR: / / State Work Done <br /> ,DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> _ Describe Material and Procedure <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 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 TITLE <br /> i <br /> (Do PLOT PLAN ON REVERSE SID <br /> FOR DEPAR NT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY I DATE a ]- 7-1�-, <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BYDATE ,/l� .-,7Z INSPECTION BY DATE/o -7Z-- -, <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 4/72 1M <br />