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SAN JOAQUIN LOCAL IIEALTH DISTRICT <br /> FOR OFFICE USE: 1 01 E. Hazelron:-Ave ",' Stockton, Calif. <br /> Telephone.: ' (20.9) 466-6781 <br /> PLICATION FOR WELL CONSTRUCTION-.,OR PUMP PERMIT Permit No. ��5�3 <br /> THIS PERMIT -EXPIRES r YEARiFROM DATE, ISSUED Date Issued z <br /> • �� ' ('Complete 'In Triplicate) <br /> Applicatioiitis..hereby-•madetto the,San,.Jo'aquin` Local Health District fo.r,.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:, J , <br /> -�and s, <br /> :the. Ruleand- Regulations,of the San Joaquin Local Health District. <br /> JOB' ADDRESS/LOCATIONf'Dj0 r)e � I: r' 7/4J 470 <br /> " CENSUS TRACT <br /> 70 : eY`:-rbc t�S13 fie-, :!U:>} <br /> Owner's Name,' 1 c r 7 r js <br /> Phone <br /> Address r- <br /> Contractor's Name _ _l R� License # Phone �Z, <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN "/_/ RECONDITION /-7 DESTRUCTION /-7 -� <br /> PUMP INSTALLATION '/ / PUMP REPAIR 6Vr PUMP REPLACEMENT /? <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS V� <br /> Industrial Cable Tool Dia. of Well Excavation O <br /> Domestic/private 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 /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. , <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: /l/ State Work Done PILO <br />(,DESTRUCTION OF WELL: Well Diameter Approximate Depth i <br /> Describe Material and Procedure <br /> j <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 /> information is true to the best of my knowledge and belief. <br /> SIGNED p � <br /> U�«+` �ti' / f iiia G " TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I r <br /> APPLICATION ACCEPTED BY DATE `A 4j '7 'L, <br /> ADDITIONAL COMMENTS; <br /> PHASE I GROUT INSPECTION PRASE I /FINAL INSPECTION <br /> INSPECTION B DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PR�OR TO GROUTING AND FINAL INSPECTION. € <br /> E H 1426 4/72 1M <br /> l <br />