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r 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: 73- �37P <br /> _ THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued <br /> S r5 (Complete In Triplicate) (moo--pS <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 o i& 4& W a ao br,4&r <br /> /� r� CENSUS TRACT <br /> C7' <br /> Owner's Name ex �od pi t,r,,_ C • x�ve �,c./ 1� <br /> �/t,�� d Phone i <br /> Address 11 !r lav City <br /> C)�j- AA1_ <br /> Contractor's Name C % o 1 a ``, License # !;C—Phone !K;k-2j.;� <br /> : _ I <br /> TYPE OF WORK (Check) : NEW WELL / / ''33EEPER' /_% RECONDITION /_7 DESTRUCTION /_ <br /> AL <br /> PUMP INSTLATION PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other / _7 i <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <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 H:P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / State Work DoneEl � <br /> ESTRUCTTON OF WELL: Well Diameter <br /> --- Approximate Depth <br /> _ <br /> Describe Material and Procedure <br /> I hereby agree ;to comply' with.-all laws and regulations of the S_aW-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 m�know�led d belief. <br /> SIGNED f {� <br /> ITLE r Cf <br /> _jPRA TP OT PLAN ON RE RSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY _ DATE <br />'. ADDITIONAL COMMENTS: <br /> PHASEII GROUT INSPECTION PHAS I INAL INSPECTION <br /> INSPECTION BY .� DATE INSPECTION BY ATE Zi <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />