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SAN JOAQUIN LOCAL HEALTH DISTRICT ' <br /> FOR OFFICE USE: 9) 1601 E. Hazelton Ave, , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.73_ <br /> 73 - 6.3.5"ya <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ., _/6-77 <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 CG,' Xk- -Ago CENSUS TRACT <br /> Owner's Name _r - _ -__ r/ � , ia.�.rJ,,� Phone q.3) V i <br /> Address / ) Ji ,G f 2 City <br /> Contractor's Name License #A, 3 73 Phone34 JV- <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN"/ /RECONDITION /_7 DESTRUCTION /? <br /> PUMP INSTALLATION AV—PUMP REPAIR / PUMP REPLACEMENT /_7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER N <br /> 6 Y d Al TT apg (LT <br /> INTENDED USE TYPE OF WELL I CONSTRUCTION SPECIFICATIONS <br /> Industrial 'L.-'Cable Tool Dia. of Well Excavation a '� <br /> Domestic/private .1 Drilled Dia, of Well Casing " <br /> Domestic/public I Driven Gauge of Casing /0 <br /> Irrigation ;1 Gravel Pack Depth of Grout Sealp <br /> Other Rotary Type of Grout -Z <br /> Other Other Infbrmation <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. 3 <br /> PUMP REPLACEMENT: / / State Work Done'-' - <br /> PUMP REPAIR: / / State Work Done:!. <br /> P.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. f <br /> SIGNED TITLE <br /> r <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE �L-_:Zy <br /> ADDITIONAL COMMENT <br /> PHA UT INSPECTION PH4SfejALFINAVANSPECTI N <br /> INSPECTION BY DATE - (- INSPECTION BY ATE <br /> CALL FOR R N ECTIONJPRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1425 j } 7/72 IM <br />'�y 7 A i b M'N .t r+ti•. M sy' T 1 1A.' Z1. 'nl ) I,.n NS F „ <br /> . ....` s' R^'': �"'7E 9.. f• M ey.. �;.. .-. y,S <br /> 4�r-r <br /> _ 'f" , ,i• tir. '� '+' J:.i.• ,:.n°::,adi>z7 � Y'°�e. '�.., 1Y:? '.,i'' �', RA'.d� y��e:� i:`.��SCi,�.,.r'.5�41E? <br />