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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. R <br /> Telephone: (209) 466-6781 C'©S - C 40 ' <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7,2-lel-2k-) <br /> 72 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) 90S- r'lo -LIO <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 /> /-a N oe-o I <br /> JOB ADDRESS/LOCATION C p L CENSUS TRACT <br /> Owner's Name K W111 Phone 6 6 i 5-LI <br /> Address !4 4, '-o City �} �E1 1�t oa elf Hifi t <br /> Contractor's Name oSS License # <br /> S_ 'f'®y Phone <br /> TYPE OF WORK (Check): NEW WELL / / DEEPEN /_/ RECONDITION /? DESTRUCTION /77 <br /> ALry <br /> PUMP INSTLATION Ly PUMP REPAIR / / PUMP REPLACEMENT /� Rt <br /> Other <br /> a ; <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 ExcavationS-o; <br /> Domestic/private Drilled Dia. of Well Casing P " ` <br /> Domestic/public Driven Gauge of Casing /7- <br /> Irrigation <br /> ZIrrigation Gravel Pack Depth of Grout Seal g'a ' <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor s' ZE,- .6 / <br /> Type of Pump _ H.P. 2- Zz,!> <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: . / J State Work Done <br />,PESTR_UCTION 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 /> SIGNED lei -yr.�/ Ye � z - � 1r� TITLE <br /> (DRABVLOT PLAN ON REVERSE SIDE <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED B DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY f �'7 -- j <br /> �_ DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. ANS r I <br /> E H 1426 7/72 1M <br />