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SAN JOAQUIN LOCAL HEALTH DISTRICT ' <br /> FOR OFFICE SE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telehone: (209)466--6781 <br /> � _ .. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No., _ 9D !rJ <br /> 7-1/ - �a P <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued7�r <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 andithe Rules and Regulations of the San Joaquin Local Health District. <br /> CENSUS TRACT <br /> JOB ADDRESS , . Ld L - <br /> Owner's Name " Phone <br /> Address : City <br /> Contractor's Name /7 `GG/ vi6�'�S License � �Phone 1�1 <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN / / RECONDITION DESTRUCTION <br /> PUMP INSTEUTION''�� ., PUMP REPAIR / / PUMP REPLACEMENT PUMP <br /> --Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES. ��'Q- PIT PRIVY <br /> SEWAGE DISPOSAL FIELDCESSPOOL/SEEPAGE PIT l04Lf OTHER --- <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool .''Dia. of Well Excavation <br /> 149 <br /> Domestic/private � Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing zZ <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary _Type xof.r Grout K <br /> Other Information <br /> PUMP .INSTALLATION: Contractor AtOftwi t c did-46r ides `S <br /> Type of Pump H.P. '. <br /> PUMP REPLACEMENT: / / State Work Done ? i <br /> PUMP REPAIR: / / State Work Done �' r <br /> ,DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> f Describe Material'and Procedure { <br /> 11 hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> j and the State ,of California pertaining to or regulating well construction. Within FIFTEEN BAYS <br /> after: completion of my work on a new well, I wil-1 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 /> : l <br /> SIGNED C TITLE <br /> ..,, —{DRAW PLOT •PLANS ON -REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I 2-- 2,6- 2/0 <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> ` INSPECTION BY DATE �2 -�. INSPECTION BY - _ DATE - —� <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> P H 1426 7/72 1M <br />