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All <br /> 11 SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE US ' : 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466 .6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.73"17T P <br /> 4 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -1y 73 <br /> (Complete In Triplicate) 173. — UY-0 `4V <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 Joaqui focal Hgxath District. <br /> JOB ADDRESS/LOCATION—Zrpp •! �� ��a s �aJ��. i o CENSUS TRACT <br /> Owners Name �� } (,jQ1� Phone <br /> Address .2 c,�j ® City <br /> tl <br /> Contractor's Name �1' iso License #/V3 "'J Phone <br /> TYPE OF.WORK (Check) : NEW WELL / / DEEPEN /7 RECONDITION /_7 DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR Zi/ PUMP REPLACEMENT /_7 <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE- PIT OTHER <br /> F <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS g� <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 <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump .02 C&,',MC H.P. / Y <br /> _ <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / State Work Done 7i''e414j,", Q Q <br /> ,pESTRUCTION 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. <br /> t SIGNED <br /> +,s (D WOT LAN ON R V RSE SIDE <br /> i <br /> OR DEPARTMENT USE ONLY <br /> PHASE I ' <br /> APPLICATION ACCEPTED BY DATE T1112_/22 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTIONPHASE II FINAL INSPECTION <br /> INSPECTION BY DATE :INSPECTION BY DATE <br /> t CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTI <br /> E H 1426 7/72 1M <br />