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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave.-, Stockton, Calif. <br /> Telephone : (209) 466 .6781 § <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ,7ny- ,2" <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued .a/D- Cf <br /> (Complete In Triplicate) 003-.1" -1 <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 and the Rules and Regulations of the San Joaquin Local Health District. <br /> 2 3 Ce 57 ,L�a �-,s <br /> JOB-ADDRESS/LOCATION V:5��'� ivl fz S A CENSUS TRACT <br /> Owner's Nam 1,A-I►�� -/VCL <br /> Address _ a �s Y. (o .�'3 _ _ City <br /> Contractor's Name _ £L7-'A ��' License 414.132_3 Phonek{- �, <br /> TYPE OF WORK (Check): NEW WELL /_7 DEEPEN RECONDITION /_7 DESTRUCTION /_7 <br /> AL <br /> PUMP INSTLATION /—/ ­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 /> W <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia.--of- Well Excavation J <br /> Domestic/private Drilled Dia.. -of Well Casing Q� <br /> Domestic/public Driven Gauge of Casing <br /> I <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor 7',� �, 1-7, <br /> Type of Pump _ S'u F 1z S; L C H.P. <br /> PUMP REPLACEMENT: P State Work Done Pu 4 L_ y �d Pu <br /> PUMP REPAIR: / / State Work Done <br /> .DESTRUCTION OF WELL. Well Diameter Approximate Depth <br /> Describe Material and Procedure �r <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 TITLE ] <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE'ONLY <br /> C PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />