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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR fl ICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.�� *7 A-�) <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued /Q_//-7.Z <br /> (Complete In Triplicate) O ,,-P Se-0 -z9- <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 q7,i, Z Z- /2 O ��7Z CENSUS TRACT <br /> Owner's Name Phone fie <br /> Address AfA-1!ll <br /> = -- City - 5h6 C 44// <br /> Contractor's Name 24_ "7"/zA lam__..._._ License #j2j3q3 Phone a 77 /9 4 <br /> TYPE OF WORK (Check) : NEW WELL ',N DEEPEN /% RECONDITION /-7 DESTRUCTION /- <br /> PUMP INSTALLATION -9 PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> �ther <br /> w <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY o <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 <br /> Domestic/private Drilled Dia. of Well Casing 6 +' <br /> Domestic/public Driven Gauge of Casing 17- <br /> Irrigation Gravel PackDepth of Grout Seal 01 <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor 719 <br /> Type of Pump H,p. <br /> PUMP REPLACEMENT: / / State Work Done " <br /> PUMP REPAIR: / / State Work Done <br /> ESTRUN F WELL: Well Diameter <br /> P CTIOO <br /> - -- _ 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 -- t � a TLE <br /> { RA OT AN ON REVERSE SIDE 1 <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I , <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: "— ) <br /> PHA I GROUT SPECTION PHASE III/FINAL INSPECTION / <br /> INSPECTION BY .. . TE - 2 INSPECTION BY ATE 3,;z 7 7 <br /> CALL FOR A ROUT IN CTION PRIOR TO GROUTING AND FINAL INSPE TION. <br /> �k E H 1426 7/72 1M <br />