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�U SM-�fYQUI�LOCAL HEALTH DISTRICT <br /> FOR OFFICEUSE: 1601 E. Hazelton Ave: , Stockton, Calif. <br /> Telephone: .(209) 466-6781. <br /> APPLICATION FOR WELL'CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date :Issued, <br /> (Complete In Triplicate) <br /> Application is.hereby.made: tb`-the'�'San Joaquin Locale Health District for a permit` ib" ^construct <br /> and/or install the work herein described. , This application is made' in to.'1.iah ce `with San Joaquin <br /> County Ordinance-No. 7862 and'the Rules ar►d Regulations of the San Jaaquin" Local Health District. <br /> _. <br /> JOB ADDRESS/LOCATION ��. 2vn aZ <br /> t�c� © �' �, i / v� 4 `CENSUS ''TRACT oo- <br /> Owner's 'Name. ✓Gr[!i tM Y 1 ---- 'Phone' Q <br /> 11- 2. . <br /> /. <br /> Address 20 V7_ v C t �! -- City <br /> Contractor's Name _ &.0aCA P0-Ao -k CaLicense #1.ran Phone <br /> dG-oLU <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN /_/ RECONDITION /_7 DESTRUCTION /7 <br /> PUMP INSTALLATION Yl PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other /_7 <br /> DISTANCE TO� NEAREST: SEPTIC TANK _ SEWER LINES PTT PRIVY <br /> � SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> )J <br /> INTENDED USE TYPE OF WELL _ a i .r CONSTRUCTION SPECIFICATIONS N <br /> Industrial Cable Tool Dia. of Well Excavation <br /> _ Domestic/private Drilled `-" Dia. f Well Casing <br /> Domestic/public # Driven. _ Gau of Casing <br /> Irrigation { ravel Pack De h of Grout Seal p <br /> Other Rotary ° .� pe o ut <br /> Other er ormation <br /> - <br /> E PUMP INSTALLATION: Co#nt act a iG <br /> ' Type Pu H.P.. <br /> f PUMP REPLACEMENT: I '/ to Work Done �. <br /> PUMP REPAIR: / i/ State Work Done <br /> .RESTRUCTION OF WELL: Well Diameter o at <br /> Describe Material and Proc <br /> s <br /> I hereby agree to comply with all laws and regulations•,of:_t Joaquin cal Health District <br /> and the State of California pertaining to or regulating wet nstr'uction. :Within FIFTEEN DAYS <br /> rafter 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 The above <br /> information is true to the best of my -knowledge and"belie€. <br /> SIGNED Tw � ..� -:°. --TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) -Ar - <br /> FOR DEPARTMENT USE ONLY <br /> I PHASE I <br /> APPLICATION ACCEPTED BY r-G Ze7 DATE <br /> ADDITIONAL COMMENTS: ' <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> F CALL FOR A GROUT INSPECTION-PRIOR- TO GROUT =--AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />