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-r- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT w <br /> FOR OFFICE USE: 601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> LICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED Date Issued q2l ! <br /> 1 (Complete In Triplicate) <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 No. 1862 andIthe Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION { <br /> CENSUS TRACT 1 <br /> Owner's Name H Phone <br /> Address — ,-3L/cg �. City K-& qtr <br /> ov <br /> oe <br /> i4 <br /> Contractor's Name _ • _ } <br /> License <br /> Phone _ <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN ./_-7 RECONDITION /-7 DESTRUCTION <br /> PUMP INSTALLATION / '/ PUMP REPAIR / / PUMP REPLACEMENT— <br /> Other / / --- <br /> 0 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY ( ' <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT. OTHER "4 <br /> INTENDED USE TYPE ,OF WELL <br /> _ Industrial CONSTRUCTION SPECIFICATIONS <br /> Cable Tool Dia, of Well Excavation) <br /> Domestic/private <br /> Drilled Dia. of Well Casing - <br />^____- Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> E <br /> PUMP INSTALLATION: ! r <br /> Contractor <br /> Type of.Pump !' ; 77, r <br /> H.P'. <br /> PUMP REPLACEMENT: / / State Work Done <br /> .. -1, 41 . <br /> PUMP REPAIR: / / State Wor' I Done - <br />-DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> C hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> ind the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> tfter completion of my workon a new well, I will furnish the San Joaquin Local Health District <br /> TELL DRILLERS REPORT of the we1`1. and notify. them before putting the well in use.' The above <br />:reform ion s true to theybest+ of myknowledge and belief. <br /> 1GNED TITLE <br /> (DRAWrPLOT.PLAN ON REVERSE SIDE <br />'RASE I FOR EPARTMENT USES�ONLY <br /> YPLICATION ACCEPTED BY DATE `-�� 7� <br /> DDDITIONAL COMMENTS: r <br /> PHASE II .GROUT INSPECTION PHASE III FINAL INSPECTION <br /> NSPECTION BY DATE _ -�' INSPECTION BY <br /> CALL .FOR A GROUT .INSPECTION ,PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 - 7/72 1M <br />