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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: .1601. E. Hazelton Ave. ,' Stockton, Calif. <br /> Telephone: (2209) 466--6781 <br /> `° = z ` • 'APPLICATION'`FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.f3_ 2137 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED , Date Issued 8 >3 <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct I <br /> and/or install the work herein' described. This application 'is made in compliance with San Joaquin <br /> County Ordinance No. 1862 and .the Ru <br /> I s aid Regula ns,,of the San Joaquin Local Health District, j <br /> .TOB ADDRESS/LOCATION �4 s CENSUS TRACT Z p2__/?0,-0/ <br /> e <br /> Owner's Name " Phone <br /> _ ! Cl _CJr cJf tri <br /> 00, <br /> Address Z-,:rg'f- //� �-+ r <br /> '� lcy�rr,.,. C ass�� l7�i � city <br /> 44 <br /> Contractor's Name �� ° License #,1aes }�/Phone <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN '/�/ RECONDITION DESTRUCTIONS <br /> PUMP INSTALLATION PUMP REPAIR/ / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD r " - <br /> CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE " TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool ; Dia. of Well Excavation r� <br /> Domestic/private Y Drilled Dia. of Well Casing <br /> Domestic/public Driven _Gauge of Casing <br /> Irrigation r <br /> g .,„ _ Gravel Pack__._._.-_ ._ Dep3:h_of�..Grout 'Seal,..¢. � Q m �, <br /> Other <_ Rotary Type of Grout <br /> Other Other Information <br /> I <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump .s"/ .. H.P- <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> ESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with al laws and regulations of the San ,Joaquin L cal Health District. <br /> and the State of California pertaining to or regulating well construction. Within FIFTEEI3 DAYS <br /> after completion of my taork on a new well, I will furnish the San Joaquin Local Health District a ; <br /> WELL DRILLERS REPORT well and notify them before putting the well in use. The above <br /> information is r to th of my kn ledge and belief. <br /> 4 <br /> SIGNED r TITL <br /> (DRAW PLOT PLAN ON REVERSE SID ? <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE ' <br /> ADDITIONAL COMMENTS: , <br /> ,PHAS I - UT INSPECTI w .-- PHASE I I/FINAL INSPECTION ' <br /> INSPECTION BY 21vDATE L2 f-7Z INSPECTION BY DATE <br /> CALL FOR A .GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPEdWON. <br /> E H 1426 4/72 1M <br />