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SAN JOAQUIN.,-LOCAL HEALTH DISTRICT <br /> FOR OFd E USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> .'Telephone: (209)' 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �:-3G�� <br /> THIS PERMIT EXPIRES -1 YEAR FROM DATE- ISSUED Date Issued %p <br /> (Complete In Triplicate) T <br /> Application is hereby made to the San Joaquin Local Health District fbt 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 ana the Rules "and Regulations of the San Joaquin Local Health District.. <br /> i , CENSUS. TRACT �. <br /> JOB ADDRESS/LOCATION 2:l%c.J � b �(f' J p /2- -_ .�f� <br /> u <br /> Owner's- Name cJ J�?'� �;/ S if -- - Phone <br /> / F <br /> Address ! C _2It l e City J� ,o C/ <br /> Contractor's Name /�?y / lf�/ L-,o h - - -- License �E fl� Dhone6 i2.Z <br /> v ry 3: <br /> s <br />�> TYPE OF WORK (Check) : NEW WELL f /" DEEPEN / / RECONDITION /� DESTRUCTION <br /> C PUMP INSTALLATION /k7 PUMP REPAIR / / PUMP REPLACEMENT <br /> Other/% — <br />�.. DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> f INTENDED USE TYPE: OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial ais f �° <br /> Cable Tool= Dia, of Well Excavation <br /> Domestic/pridate .1 Drilled Dia. of Well Casing. G\ <br /> Domestic/public ! Driven. Gauge of Casing <br /> r <br /> Irrigation i t "Grave;. Pack Depth o,f. Grout Seal.. + <br /> Other 1 Rotary 'Type of Grout' <br /> t Other Other Information <br /> PUMP INSTALLATION: Contr actor f D <br /> ,` <br /> Type of Pump ' H.P. - --- <br /> g � a �' •" y' 3 tf I <br /> i ! 'F r a• i a <br /> PUMP REPLACEMENT: / / State"'work Done <br /> PUMP REPAIR: / / State Work Done <br /> pESTRUCTION OF,WE_LL: 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 constrilction. Within FIFTEEN DAYS <br /> s +after cumpletim)-o'f` my work on'a'new well, I will furnish the San Joaquin Local Health District a <br /> t ,WELL DRILLERS REPORT of the well and notify them before putting the'well in use. The above. <br /> y information°.is true to the ibest.,of my: knowledge .and belief. ,! <br /> <SIGNED¢ _ TI'T'LE <br /> (DRAW PLOT PLAN ON REVERSE SIDE... . 1. <br /> k . , FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY 3 6ATE . / rI � a <br /> �,-ADDITIONAL COMMENTS: r <br /> •. :PHASE.II GROUT. INSPECTION PHASA IU FI AL INSPECTIO <br /> INSPECTION BY E sT' -DATE DATE <br /> CALL FOR A GROUT,,,INSPECTION 'PRIOR TO GROUTING AND FINAL INSPECT jg <br /> F <br /> E H 1426 - r 7/72• :IM <br />