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KV_55�rll_ <br /> 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.�� - 3p <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued Ja-/y.-7.2 <br /> A$� -� (Complete In Triplicate) OF(, C(-6-C) -05 <br /> pp cation is °here y 4e- 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 Joaquii <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 3iY1 e. 1�e/l��/✓ <br /> 0 I� •IY o o prr o� p CENSUS TRACT <br /> Owner's Name 0.urj Sd 14 r"o Phone ' t?3l — /aDL <br /> Address 20 7 �.. L / r A o. City U�._/eil' — <br /> Contractor's Name H1T License # <br /> L93 7 y�Phone62 <br /> TYPE OF WORK (Check): NEW WELL / / DEEPEN /_/ RECONDITION /_7 DESTRUCTION /? <br /> PUMP INSTALLATION /_1 PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other <br /> f DISTANCE TO NEAREST: SEPTIC_TANK. SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL.FIELD CESSPOOL/SEEPAGE PIT OTHER Q <br /> ' INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> f Industrial Cable Tool Dia, of Well Excavation j <br /> Domestic/private Drilled Dia, of Well Casing fix. <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation . Gravel Pack Depth of Grout Seal <br /> Other Rotary Type.of Grout <br /> OtherOther Information <br /> PUMP INSTALLATION: Contractor Q L <br /> r <br /> Type of Pump _a <br /> �y, H.P. <br /> PUMP REPLACEMENT: / / State[nWork'boiie <br /> PUMP REPAIR: State Work Done <br /> ,DESTRUCTION OF WELL: Well Diameter Approximate Depth. <br /> Describe Material and Procedure <br /> i <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 ander lief. <br /> SIGNED ){d rc TLE a1' <br /> {DRAW P T PLAN -ON RE SE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: ' <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72. IM <br />