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{ <br /> C ' f SAN JOAQUIN LOCAL HEALTH DISTRICT ' <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No, ,Z2- L±fle <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -7-1- <br /> (Complete <br /> 7Z(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 /> JOE ADDRESS/LOCATION LS $ ; c CENSUS TRACT <br /> Owner's Name (.�,E Phone <br /> Address 1.S S,3 0 dLt Lj_u City- <br /> Contractor's Name c )�u., r` , License # g .17� Phone <br />'-TYPE-'OFTWORKF(CheckT NEW`W -L-L-"-/7DEEPEN J_/ RECONDITION /7 DESTRUCTION <br /> DESTRUCTION / <br /> PUMP INSTLATION REPAIR / __PUMP REPLACEMENT /7 <br /> Other /_7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER rt- <br /> i W <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIQNS <br /> Industrial Cable Tool Dia. of Well Excavation. b <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 <br /> Other Other Information <br /> a <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIRa !� <br /> X/ State Work Done � �.. - <br /> ESTRUCTION 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 �_ �� �; � '29. ��� _ TITLE )7 <br /> )?u,��L� 1J <br /> (DRAW PLPLAN ON REVERSE SID - <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY _ _ _ DATE \? <br /> ADDITIONAL COMMENTS: <br />` PHASE II GROUT INSPECTION PHA III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE 3 -13 <br /> r_ CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H ,-142"6 7/72 1M y <br />