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y✓� 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. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date -Issued 2,,J,3 <br /> �d4b 'S - 1 lLAfv �/L'Fj (Complete In Triplicate) 131 _ (,c-0 -C-> <br /> Application is hereby made totthe San Joaquin Local Health District for a permit to construct <br /> and/or install the work herein described. This application is shade in compliance with San Joaquin; <br /> County Ordinance No. 186 d}.the Rules and Regula i n of the San Joaquin Local Health District. ; <br /> JOB ADDRESS/LOCATION I41'1 ] 4 ,.-f Tom Z CENSUS TRACT <br /> Owner's Nance ��[� � p T .IV Phone � <br /> i <br /> r <br /> Address -- - Q _ g ox 4�) T City 73—F-0 C l< 7_8W <br /> Contractor's Name / !'/V(-- License # Phone <br /> TYPE OF WORK (Check): NEW WELL / / DEEPEN / - RECONDITION /7 DESTRUCTION / <br /> PUMP INSTALLATION / I PUMP REPAIR / / PUMP REPLACEMENT /_ <br /> Other /. / — <br /> Q <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PTT PRIVY o f <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER a { <br /> h <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation <br /> Domestic/private Drilled Dia, of Well Casing t <br /> Domestic/public Driven 'Gauge of Casing <br /> Irrigation a Gravel Pack Depth of Grout Seal <br /> Other 1 Rotary Type of Grout <br /> 1 Other Other Information <br /> c x <br /> PUMP INSTALLATION: Contractor <br /> Type of.- Pump H.P. ' <br /> _ f i <br /> PUMP REPLACEMENT: / / State Work Done i <br /> � 7 <br /> PUMP REPAIR: / / Skate Work Done <br />,DESTRUCTION OF WELL: Well Diameter 3 / 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 TITLE 0)I/ 77/V C 7-0 !� <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY �(, DATE <br /> ADDITIONAL COMMENTS: F��_ <br /> PHASE II GROUT INSPECTION PIJASFI /FINAL INSPECTION } <br /> INSPECTION BY DATE INSPECTION B ATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUPING AND FINAL INSPE TION. <br /> E H 1426 7/72 1M <br />