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SAN JOAQUIN LOCAL HEALTH DISTRICT i <br /> FOk.:OFFICE USE: w . 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 73- 31��2p <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 7- Ir- ,,-3 <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health Distract 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 vh®e`the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESSILOCATION �s+'i 4aUS.b 0.1 ZOW9 CENSUS TRACT <br /> Owner's Name 0^C. Phone <br /> Address - - ..7 01116 E$Y/:lb w City ' ' t <br /> Contractor's Name Li.cense # j U.CoPhone <br /> TYPE OF WORD (Check) : NEW WELL / / DEEPEN '/_ RECONDITION /_/ DESTRUCTION /_7PUMP INAL <br /> STLATION PUMP REPAIR '/—/ PUMP REPLACEMENT /_7 t <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER v <br /> INTENDED USE TYPE:OF WELL CONSTRUCTION SPECIFICATIONS <br /> indu5 tra a1 ` ; .... ,- Cable Tool ,. Did'-. of 'Well Excavation <br /> .Domestic/private. ! ......... Dr.ill.ed. ...Dia...of.,Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Trrzaton:..... 'Gravel Pack Depth of Grout Seal <br /> Other . . .'..... . ....:. .. .....Rotary.. T'ype._.of. Grout ? <br /> Other Other Information <br /> i <br /> PUMP.. ... . . . ... .... ..:.......: . . ...... .... . .. .. ... . <br /> i <br /> INSTALLATION: 'Contractor <br /> : ..._ITyP'e of Primp H.P. ' f <br /> . I "� <br /> PUMP State Work Don_,_,;.,. . . e ,��'�/�,� __ _/s�0 4j 4I'u_,�qW A-0--.!"i jAA6 <br /> PUMP "tEPAIR:. .. fes. / State.Work Done <br /> DF.TRUCTION OF WELL:' Well'Diameter" " Approximate Depth <br /> :.. . . Describe Material and Procedure _ <br /> I hereby agree to'coinply with all laws and -"regulations of the San Joaquin Local health District <br /> and the .Stat.e; of: Calif.oxnia.pertaining.to or regulating well ''construction. Within FIFTEEN DAYS + <br /> after completion' o.f-my .work on a- newt well, I will _furnish .the San Joaquin Local Health District a <br /> WELL DRILLERS: `REPORT"6f- the x4611 and notify these before putting the well in use. The above 4. <br /> information is..true,,.to 'the_ best of.. qty,knowledgeaadbelief.. <br /> SIGNERLEr �(' <br /> . . : :.... PLOT_ PLAN ON RE RSE. SIDE) . ... <br /> FOR DEPARTMENT USE ONLY x <br /> PHASE I <br /> APPLICATION--ACCEPTED ... <br /> BY . .. :.. DATE <br /> ADDITIONAL COkMNTS: <br /> `PfIASE II GROUT INSPECTZ©N PHASE III/FINAL INSPECTION <` <br /> INSPECTION .BY; .. ..... .. :.....DATE..T... INSPECTION .BYDATE._. <br /> L—C"ALL F�QRTA--GROUT-;'•1 9FECT.ION VRIOR..TO.._GROUTING AND-FINAL..INSPECT. <br /> Lc u 11/.0c' �/727u <br />