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SAN JOAQUIN LOCAL HYALT11 DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> � " r ^ Telephone: (209) 466-6731 <br /> PLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No j Z�_ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Data Issued 1� -7 Ti <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 CENSUS TRACT <br /> Phone /v <br /> Owner's Name �� ic, '�- � UL(�-(J� r ln: �, <br /> ge , j <br /> AddressCity' o Ci.t <br /> -- Y <br /> Contractor's Name 4�a License # % Phone Z 7--3,j <br /> VV <br /> TYPE OF WORK (Check) : NEW,WELL /� DEEPEN /? 5-RECONDITION /� DESTRUCTION /� <br /> PUMP INSTALLATION `, PUMP REPAIR '/ / PUMP REPLACEMENT /_7 <br /> Other /, // <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY r <br /> SEW GE DISPOSAL FIELD _ CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation, nA <br /> Domestic/private Drilled Dia, of Well Casing 2^ t <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation. ..,Gravel Pack— Depth- of-Groiit-Sba1-4-- <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> ! I 6 f <br /> PUMP INSTALLATION: Contractor �li� <br /> Type of Pump t � (}�� H.P. vr - f <br /> PUMP REPLACEMENT: Sta te,Work <br />-PUMP REPAIR-:— js'trk-_Done .�. -r� �A � ' - -- <br /> ` --SOY <br /> r . <br />,DESTRUCTION OF WELL: Well Diameter Ab Jr-,0-4,,_41' -Approximate Depth € <br /> Describe Material and Procedure- <br /> - <br /> I hereby-agree-'to-com 1 with*-all--.laws--and regulationg' of the-,San•'Joaquin Local..Health Distr2AYS <br /> P- Y' g � <br /> and the State of California pertaining 't6_ or-reguYa'ti.ng well construction. Within FIFTEEN D <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health Distr <br /> WELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> information is true to the b st of my knowledge and belief. <br /> �SIGNED a° % J,,� (_�4 TITLE �`�� iRAW PLOT PLAN ON REVERSE SIDE)—FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY �� DATE 77 <br /> ADDITIONAL COMMENTS: ; <br /> PRASE II OQUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE '20- - y <br /> CALL�.,F'OR A GROUT NSPECTION PRIOR TO GROUTING ANDFINAL INSPECTION. _ <br /> E H 1426Y 4/72 ]M <br />