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` t t <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> MR-OFFICE USE: 1601 E. Hazelton'Ave. ,' Stockton, Calif. <br /> Telephoner: (209),,466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 3 S��CcJ <br /> . .. _ <br /> THIS PERMIT EXPIRES l YEARFROM -DATE' ISStEDDate Issued. <br /> g4iv �e.lo4J,c ,2_� (Complete In Triplicate) p"2t - CCo®,--1 2— <br /> Applicationis 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 msde'`in-'compliance with San Joaqui•; <br /> County Ordinance No.' 1$62land the`Rules and Regulations of th San Joaquin' Local Health District. <br /> JOB ADDRESS/LOCATIO zgoC <br /> - �S^ .TRACT -- <br /> Owner's Name A 0 C' r- C— Phone <br /> Address Ci.ty. <br /> Contractor's Name 1LL/ icense 14,2 hone <br /> TYPE OF WORK (Check): NEW WELL / DEEPEN /_%PRECONDITION /� DESTRUCTION /_7 . <br /> - PUMP ,INs_T ...LAT_ION % / PUMP REPAIR / / :PiJMP REPLACEMENT /_7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TAN SEWER LINES PIT PRIVY <br /> SEWAGE DISP AL FIELD CESSPOOL/SEEPAGE PIT OTHER ' <br /> INTENDED USE` TYPE OF WELL CONSTRUCTION SPECIFIC IONS <br /> - Industrial Cable Tool Dia. of Well Excavation ' <br /> Domestic/private Drilled Dia. of Well Casing Q JV <br /> Domestic/public Driven Gauge of Casing , <br />. Irrigation .,._ ..�;_ .,�. .�. . Xravel_ Pack ..Depth. ofr.Grout Seal - <br /> Other Rotary Type of Grout <br /> Other Other Information" <br /> ' <br /> PUMP INSTALLATION: Contractorf <br /> Type of Pump H.P. <br /> _ t <br /> PUMP REPLACEMENT: / / State Work Done <br /> , <br /> PUMP _REPAIR: J /. State Work Done <br />.RESTRUCTION 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 4 <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 iue to the'--b-es my knowledge and belief., �` <br /> S <br /> SIGNED :. 'TITLE • <br /> (DRAW 110f_—PLAN ON REVERSE SIDE <br /> -A <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY _ _ DATE e)6 <br /> ADDITIONAL COMMENTS: -- <br /> PHASE II GROUT INSPECTION PHASE-III/FINAL INSPECTION <br /> INSPECTION BY DATE -INSPECTION,.BY,_ ,g - DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />