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S �A <br /> ✓� AN JOAQUIN LOCAL HEALTH DISTRICT <br /> .,OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: ..,(209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �3 3�! <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made. to the San Joaquin Laca1 Health .District for a permit to construct <br /> is made in compliance with San Joaquin <br /> and/or install the work herein described. This application <br /> County Ordinance No,�!1$62 and the Rules and ,Regulations of- the San Joaquin Local Health District. <br /> s <br /> CENSUS TRACT ' <br /> JOB ADDRESS/LOCATION <br /> Phone ! ;9z i <br /> Owner's Name <br /> _ City <br /> Address 54 <br /> Phone <br /> Contractor's Name UGy' s <br /> fd.c44�Jr <br /> License <br /> TYPE OF WORK (Check) NEW WELL DEEPEN !I RECONDITION / / DESTRUCTION J�T <br /> PUMP INSTALLATION PUMP REPAIR /:/ PUMP REPLACEMENT 1_7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TA1NK SEWER LINES PIT PRIVY <br /> SEWAGE DISP SAL FIELD CESSPOOL/SEEPAGE PIT OTHER v <br /> b 6 A <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> '� Cable Tool` Dia. of Well Excavation <br /> " Industriail -, � <br /> �T Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation ' Gravel Pack' Depth of Grout Seal <br /> Other 4IN Rot.Ary fi Type of Grout- <br /> --- Other's Other Information ' <br /> PUMP INSTALLATION: Contractor /!� H.P. l� <br /> Type 'of Pump <br /> PUMP REPLACEMENT: i!/ State Work Done <br /> � s <br /> t PUMP `EPAIR: / / State Work Done _ <br /> if Approximate Depth <br /> ,DFRTRUCTION Off' WELL: Well Diameter <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 Co or regulating well"construction. Within FIFTEEN DAYS <br /> after completion of my work a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT 'of h'e�ell and notify them before putting the well in use; The above <br /> information .is e d the best of .my kr►owledg� belief. <br /> TITLE - <br /> SrGNED ( W PLOT PLAN ON REVERSE SIDE) <br /> � . FOR DEPARTMENT USE ONLY <br /> PHASE I DATE Z <br /> APPLICATION ACCEPTED -BY <br /> ADDITIONAL COMMENTS.; 'SE 11/FINAL. IN5PETN <br /> PHASE II GROUT INSPEC ON DATE l l <br /> INSPECTION BY _ DATE INSPECTION BY <br /> { CALL-F'OR-A�GROUT•-INSPECTION..PRIOR TO. GROUTING AND -FINAL_INSPECTIO 5/73 <br />