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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. i <br /> Telephone: (209) 466-6781 j <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 73--160 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued '1.10- 73 <br /> f.j (Complete In Triplicate) <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 ules and Regulations of the' SanVJoaquin Local, Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT I <br /> i <br /> Owner's Name 0 eA 95 1Phone G Z z! 7l> <br /> Address <br /> O � L City <br /> Contractor's Name r <br /> y e e � License ��a Phone 4, <br /> I <br /> TYPE OF WORK (Check) : NEW WELL /7 DEEPEN /_/ RECONDITION /7 DESTRUCTION /-7 <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT /_ <br /> Other /% <br /> F € <br /> DISTANCE TO NEAREST: SEPTIC TANK i SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER 1 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> _ Industrial I Cable Tool Dia, of Well Excavation <br /> Domestic/private f 1 Drilled Dia. of Well Casing <br /> Domestic/public I Driven Gauge of Casing J <br /> Irrigation I Gravel Pack Depth of Grout Seal <br /> Other I Rotary Type of Grout <br /> 1 Other Other Information <br /> I � ! <br /> PUMP INSTALLATION: <br /> Contractor <br /> Type of Pump <br /> "..M."" H.P. <br /> PUMP REPLACEMENT: / / State Worts Done { <br /> PUMP REPAIR: / / State Work Done j <br /> ESTRUCTION OF WELL: Well Dimeter I 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 onla 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 <. � 0 .sf`� ITLE <br /> ' (B W PLOT AN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I c��� .... <br /> APPLICATION ACCEPTED BY DATE Ili/ <br /> ADDITIONAL COMMENTS: t ; <br /> PHASE II GROUT INSPECTION PHAS I FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPE ION. <br /> E H 1426 7/72 1M <br />