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SAN JOAQUIN LOCAL UEALTH DISTRICT <br /> FOR OFFIC9 USE: 1601 E. Hazelton Ave . , Stockton, Calif. <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Lpplication` is hereby made to the San Joaquin Local Health District for a permit to construct <br /> ind/or install the work herein described. This application is made in compliance with San Joaqui <br /> ;ounty Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> -77 3 s� �'"N► G w ar.;4 - 1 0 <br /> SOB ADDRESS/LOCATION t� 13/ _ 1 ,� ' .� �vr^rr m.•- D� ��� CENSUS TRACT 2p/_ 02,,c-03 <br /> ►wner's Name i-�- cm �r r� Phone <br /> Lddress /3— 4 ?7 n 10 /?j .r–d 0 /C City <br /> ;ontractor's Name d {r` 4, License # /�r'Phone <br /> 'YPE OF WORK (Check) : NEW WELL / / DEEPEN /_7 RECONDITION /_/ DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR REPLACEMENT /_7 <br /> Other <br /> J <br /> ►ISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY k <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 J <br /> Other Other Information <br /> 7 <br /> 'UMP INSTALLATION: <br /> Contractor <br /> Type of Pump ` H.P. / <br /> 'UMP REPLACEMENT: / State Work Done _ �� D lq, R n of <br /> 'UMP REPAIR: / / State Work Done t� <br /> 1ESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> ind 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 /> TELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> .reformation is true to the best of my knowledge--and belief. <br /> ;IGNEDTLE <br /> `-( W P PLAN ON ERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> 'RASE I <br /> APPLICATION ACCEPTED BY DATE <br /> LDDITIONAL COMMENTS: <br /> P II GROUT INSPECTION PHAS I FINAL INSPECTION <br /> INSPECTION BY,/ 1 DATE f -� INSPECTION BY DATE 1171 <br /> z <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M C� <br />