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r 0" SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. 73 <br /> Telephone: (209) 466-6781 'J�/ SU <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ZJ! 1>7,? <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued / 3 <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 /> /67 a`rO IF- <br /> JOB �9/LOCATT�14M .Y t S ENSUS TRACT <br /> Owner's Name Phone <br /> Address -Q4rL Fav rt a vt Le - City, ye't _. .. <br /> Contractor's Name / License 14. Z6a Phone L' <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN /_/ RECONDITION /_7 DESTRUCTION /_ <br /> PUMP INST LATION PUMP REPAIR / / PUMP REPLACEMENT /? <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK . SEWER LINES<no_ + PIT PRIVY .� <br /> SEWAGE DISPOSAL FIELD/"_fCESSPOOL/SEEPAGE PIT OTHER Q <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 ZZ <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor /14A494 2IIA44 4 4&�� J;;&;� <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / J State Work Done <br /> ,DESTRUCT ON 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 TITLE 6W&AeA�e <br /> (DRAW PLOT PLAN ON REVERSE SIDE)-- <br /> R DEPARTMENT USE ONLY <br /> PHASE I r <br /> APPLICATION ACCEPTED B .cJ DATE oS <br /> ADDITIONAL COMMENTS: r <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY A, DATE J!T- INSPECTION BY ,42 DATE --je,-Z � <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. ►nt14 <br /> E H 1426 7/72 1M <br />