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#FICE <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT USE: 1601 E. Hazelton :Ave. , Stockton, Calif. 4 <br /> Telephone: (209) 466-6781 ; <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 73---Y.2�T1 <br /> THIS PERMIT_ EXPIRES 1 YEAR FROM DATE ISSUED Date Issued9-1 <br /> (Complete In Triplicate) f <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 Na-. .1862 and..the Rules- and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION - ` M Lh CENSUS TRACT Its <br /> i x <br /> Owner.'-s. Name �. �. �� row.. Phone' 'S <br /> Address - � `off it <br /> Cit <br /> Contractor's Name C j(z 3. „ - ----Y License # Phone <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN '/ j RECONDITION /_/ DESTRUCTION /� I <br /> PUMP INSTALLATION/ / PUMP REPAIR/ / PUMP REPLACEMENT [7 ' <br /> Other ./% --- <br /> DISTANCE TO NEAREST: SEPTIC TANK jhn.. SEWER LINES PIT PRIVY <br /> SEWAGE DISPO AL FIELD �(�U CESSPOOL/SEEPAGE PIT OTHER Q <br /> d <br /> INTENDED USE . TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private - K Drilled Dia. of Well Casing " <br /> Domestic/public Driven. Gauge of Caping. /2 � <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout TT� <br /> Other Other Information -- <br /> PUMP INSTALLATION: Contractor Owr1,0f'. <br /> Type of Pump ' H.P. <br /> t 3 <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State .Work Done <br /> t <br /> ,DESTRUCTION 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 /> informatio is true to tATe best of my knowledge and,b-elief. <br /> 1 <br /> SIGN TITLE <br /> .7 (DRAW PLOT PLAN ON REVERSE SIDE . <br /> IF FOR DEPARTMENT USE ONLY <br /> PHASE I n <br /> APPLICATION ACCEPTED BY AJ9A4&6DATE RVI-? <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHA&ION. <br /> /FINAL INSPE ON I <br /> INSPECTION BY DATE INSPECTION BY DATE 3 <br /> CALL FOR A GROUT INSPECTION PRIOR TO 'GROUTING AND FINAL TNS � <br /> E H 1426 4/72 1M <br /> G\> <br />