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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. � 7 <br /> 4 <br /> THIS PERMIT EXPIRES l YEAR FROM 'DATE ISSUED , Date Issued LS -?-z, <br /> (Complete In 'Triplicate) -'ZS'0" 2-y-0-``0l <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 incompliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> f <br /> SoO T.PA,-YAc'.cyr°?c�c - CENSUS TRACT <br /> JOS ADDRESS/LOCATIONm - <br /> Owner's Name Phone <br /> Address �./�� 4h,2,0 City <br /> Contractor's Name License # ILS Phone <br /> TYPE OF WORK (Check): 14EW WELL /—T DEEPEN/WT RECONDITION /_� DESTRUCTION /_7 <br /> PUMP INSTALLATION PUMP REPAIR /X/ PUNK' REPLACEMENT /-7 ; <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 k <br /> Domestic/private Drilled Dia. of Well Casing { <br /> y <br /> Domestic/public Driven Gauge of Casing <br /> - Irrigation- _ Gravel Pack Depth of Grout Seal ;f <br /> Other Rotary Type of Grout <br /> Other Other Information . . <br /> - e <br /> b, <br />` PUMP INSTALLATION: Contractor LA^"" 7S <br /> Type of Pump H.P. l # <br /> PUMP REPLACEMENT: / / State Work Done "° <br /> PUMP REPAIR: /_7 State Work Done <br /> ,DESTRUCTION OF WELL: 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 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 /> {�4 information is true to the best of my knowledge and belief. <br /> SIGNED TITLE a 111 <br /> 6V (DRAW PLOT YLAN ON REVERSE SIDE <br /> F FOR DEPARTMENT USE ONLY <br /> � PHASE I <br /> APPLICATION ACCEPTED BY 6 /, DATE -7 2 <br /> ADDITIONAL COMMENTS: <br /> PHAS 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 4/72 1M <br />