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1 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FF04RiF!FM=ICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 ' <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. '73_ j_ 2 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued Fs-t1 <br /> (Complete In Triplicate) <br /> Application is,hereby made totthe 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 /> JOB ADDRESS/LOCATION42 7 4 CENSUS TRACT <br /> Owner's Name f//j a � /�} 1�. Phone <br /> Address _ Z 70-7 A F,4 R&C-0 City 5 ryc f�74 N_ <br /> Contractor's Name CI_A JN2aL + fa U I_I�_ 4:0, License # L402 Phone <br /> TYPE OF WORK (Check): NEW WELL / / DEEPEN /_7 RECONDITION /7 DESTRUCTION 17 <br /> PUMP INSTALLATION /—/ PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other 1/_7 <br /> DISTANCE TO NEAREST: SEPTIC DANK SEWER LINES PI-T, PRIVY Y <br /> SEWAGE+:DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool `.-' -Dias--of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of,'Casinj _T LZ <br /> Irrigation -- "- Graver-Pack - Depth of Grout Seal <br /> Other I Rotary :.Type of Grout CZ A e <br /> 1 Other Other Information <br /> v r _ <br /> PUMP INSTALLATION Contractor =J // 9 ! C f <br /> 4 Type of Pump j ,, "`' H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> L' PUMP REPAIR: / / State Work Done <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 I <br /> information is true to the best of my knowledge and belief. E <br /> SIGNED d , TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I _....� �' <br /> APPLICATION ACCEPTED BY DATE - <br /> ADDITIONAL COMMENTS: - <br /> PHASE II "Mr I ECTIO PHAS III F AL INSPECTION, <br /> 2 <br /> INSPECTION BY DATE . INSPECTION BY 4V DATE <br /> CALL FOR A GR INSPECTION PRIOR TO GROUTING AND FINAL INSPE J ON. 4 <br /> F E H 142649 7/72 1M <br />