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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FEREICE 1601 E. Hazelton' Ave. , Stockton, Calif. <br /> Teleplone (209) 466-6781 <br /> APPLICATION FOR-WELL CONSTRUCTION OR PUMP PERMIT Permit No -73 <br /> 1 <br /> THIS :PERMIT EXPIRES 1 YEAR FROM'DATE ISSUED 1 Date Issued: ./ -�</7� <br /> (Complete In Triplicate) �7 <br /> Application is her'e'by'' made't o, the: San Joaquin Local Health District. for a periniti to construct <br /> and/or install the work herein described. This application is made ' n compliance-with San Joaquin <br /> County Ordinance No: 1$62 and` the Rules and' Regulations of the San Joaquin Local Health 'District. <br /> JOB ADDRESS/LOCATION J17 'Wea4tl"e,42 CENSUS TRACT <br /> owner's Naim y� --- Phone 22' 1_V4l. <br /> Address _ 2l 7 • I�'�s 1�C'Lc3- -12G! �u' �• �-a�. _ City <br /> Contractor a Name License 16/ Phone S7a -. Z 13 <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN / / RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT -7 <br /> Other /_7 <br /> DISTANCE TO NEAREST: SEPTIC TANK -!� SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD ---+ CESSPOOL/SEEPAGE PIT r--- OTHER <br />{ INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable.Tool Dia. of Well Excavation 61'` ', <br /> E.— Domestic/private �f�Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing -� <br /> Irrigation Gravel Pack Depth of Grout Seal 5_0 a <br /> Other Z_-Rotary Type of Grout f <br /> Other Other Information (! <br /> + <br /> PUMP INSTALLATION: Contractor - - - <br /> Type of Pump H.P'. <br /> r • O <br /> t PUMP REPLACEMENT: / / State Work Done j•7�yur�G . v K� ce <br /> _ k Aiecv -ell zoo :v l ex <br /> PUMP REPAIR: / / State Work Done <br /> ESTRUCTION OF WELL: We11 :Diameter . tr Approximate Depth IS'7J <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 i 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 /> l information is true to the best of my knowledge and belief.. <br /> SIGNED TITLE <br /> (BROW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPA&TMENT USE ONLY <br /> iPHAS E I <br /> ± APPLICATION ACCEPT % BY DATE ._g � — <br /> ADDITIONAL COMMENTS: <br /> { PHASE II GROUT INSPECTION PHASE I I FINAL INSPECTION <br /> ( INSPECTION BY DATE INSPECTION BY D .� <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. 7/72 IM <br /> E H 1426 ' <br />