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_ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE:OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. V <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 E�7/ <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Focal Health District for a permit to consL uct € <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 Satz Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION S' CENSUS TRACT - <br /> A <br /> Owner's Name. 1�.E'.F'.� SS' Phone 5?-ZS-- gf,-1.f 7 ._ <br /> Address ti. - /'�� .E'�-. ,��F' _ City' . � <br /> Contractor's Name ,eLicense 3 Phone ,"yI <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN/ / RECONDITION / / DESTRUCTiON /? <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /_7 C7� <br /> Other -/ / — <br /> 7 <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 <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/pri'vate Drilled Dia. of Well Casing ��.as221L <br /> Domestic/public Driven Gauge of Casing /�� Gr✓/�r� <br /> Irrigation Gravel Pack Depth of Grout Seal J 0_ <br /> Other Rotary Type of Grout .�. - <br /> .yl�yl�YY��.•.•.• Other Other Information S", -- .�� g2,r U.Fi� <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> 4 <br /> PUMP REPLACEMENT: / / State Work Bone <br /> PUMP 'tEPAIR: / / State Work Done <br /> .DFCTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> t <br /> I hereby agree to comply with all haws 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 /> atter completion of my work on a new well, I will furnish the San Joaquin Local Health District a k <br /> 14ELL 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 /> SIGNEDr TITLE CI/_c <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED .BYDATES <br /> ADDITIONAL COMMENTS: <br /> ZOE <br /> PHASE II GROUTINSP CTION PHASE I I4FINA INSPE TION f <br /> INSPECTION BY DATE INSPECTION BY DATE -] y--_7 <br /> CALL FOR ARO T INSPECTION-PRIOR TO GROUTIN_ AND FINAL INSPECTION. <br /> H 142b ze � -v+ - te t�,� ; lc.l .�. 5/'73z <br />