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SAN JOAQUIN LOCAL HEALTH DISTRICT � <br /> F0 OFFICE USE: 4 r . 1601 E. Hazelton Ave. , Stockton; Calif. <br /> Telephone: (209) 466 6781 <br /> APPLICATION FOR WELL CONSPUCTION OR PUMP PERMIT Permit No.7 3 "7 Z_ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'TSSUED , Date Issued ?L <br /> (Complete In Triplicate) (7- S--7 7 2•-� <br /> Application' is hereby'made ;to the San Joaquin Local Health District for a permit to construct EE <br /> and/or install the work herein described. This application is made in with San Joaquin ; <br /> County Ordinance N .' 1862 and the Rules and 'Regulations of the San, Joaquin Local Health District. i. <br /> JOB ADDRESS/LOCATION [s- `a•c1a_ Sintyt ✓ C S TRACT s <br /> Owner's Name _X//h9 *yI_N c hlw :a_4� Phone 46 Oil �a3 -- <br /> Address cz�x-r City S 7`/r`if/ C,-4-fly <br /> Contractor's Name License # —,,#Phone 74S'1�5�- <br /> i <br /> TYPE OF WORK (Check) : NEW WELL - DEEPEN '/_ RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT /? i <br /> Other /_7 <br /> i <br /> DISTANCE TO NEAREST: TSEPTIC TANK 7 0 ` SEWER LINES PIT PRIVY p <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial ,X. Cable Tool Dia, of Well Excavation /0 <br /> _) Domestic/private Drilled Dia. of Well Casing Ir <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal O <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor b 5-7& <br /> w: Type of Pump H.P. <br /> PUMP REPLACEMENT: /_7 State Work Done <br /> PUMP REPAIR: / / State Work.Done <br /> ,DESTRUCTION 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. Y <br /> SIGNED TITLE <br /> (DRAM 0 PLAN ON REVERSE SID <br /> FOR DEPARTMENT USE ONLY <br /> PHASE i <br /> APPLICATION ACCEPTED BY DATE��" _ <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE II FINAL INSPECTION <br /> INSPECTION BY DATE , INSPECTION BY DATE <br /> �. <br /> CALL FOR A GROUT INSPECTION ,PRIOR TO GROUTING AND FINAL INSPECTION. . <br /> E H 1426 - - Y - _. _ _ _. �� - - - - 4/72 IM <br />