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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. fy.3/ Lc) <br /> THIS PERMIT -EXPIRES l YEAR FROM DATE ISSUED Date .Issued <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 /> TRS L DURESS/LOCATI,ON 4) fJ� ENSUS TRACT Ell -Z"7' - Q3 <br /> F�l��JK <br /> Owner.'s NameeA274_T- 1Ee�_aLdP_1�/�/a .�5 Phone <br /> Address :- fV• City <br /> Contractor's Name_ `~ f� License #,,2 , <br /> �._ <br /> TYPE OF WORK,(Ch ckc)t� aNEW'TWELLIALLA'TION '/ <br /> r DEEPEN /? RECONDITION /7 DESTRUCTION /-7 ' I <br /> PUMP INS / PUMP REPAIR "/ / PUMP. REPLACEMENT <br /> f J Other L-1 <br /> DISTANCE'0 NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER ` <br /> �4 7 { j <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFIC IONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of-Well Casing? <br /> D mestic/public Driven Gauge"of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal Z . <br /> Other l Rotary Type of Grout 1 <br /> i <br /> Other Other Information- <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP .REPLACEMENT: -- / '/'-St-ate-Work-Done <br />` PUMP REPAIR: % - ^ <br /> State Worms k Done � <br /> i .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 /> k WELL DRILLERS REPORT of the` wellrand notify them bgfore_putting the well in use. The above . <br /> information true to the b o my, knowledge and belief. <br /> SIGNED a a TITLE <br /> -(DMW PLOT PLAN ON REVERSE SID <br /> FOR DEPARTMENT USE ONLY <br /> PHASE ! <br /> APPLICATION ACCEPTED BY `_.. DAT - Y <br /> ADDITIONAL COMMENTS: I � <br /> PHASE If GROUT INSPECTI N PHASE II ,FINAL IN EC IOD <br />' INSPECTION BY f DATE . -;/3 i��. INSPECTION BY DATE :. -73',� <br /> r CALI. FOR A GROUT. INSPECTiON PRIOR. TO GROUTING AND FINAL INSPECTION. <br /> 4/72 IM <br /> E H 1426 <br />