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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. <br /> 3-31 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued, -IV- 3 <br /> ;! (Complete" In Triplicate) <br /> Application is hereby madeto the San Joaquin Local Health District fora permit to construct <br /> and/or install the work herein described. This application is made in compliance with San Joaquir <br /> County Ordinance No. 1862 aAd the' Rules and Regulations of the San Joaquin Local Health District. <br /> 4 <br /> JOB ADDRESS/LOCATION /S7 �i �- CENSUS TRACT <br /> Owner's Name `r1p r-E-'f_r t�_ �r1 �r� - Phone <br /> Address �S � �R City UC�c - <br /> Contractor's Name License #/ Y!Phone 27671 <br /> . TYPE OF WORK (Check) : NEW WELL /_ DEEPEN RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR /X/ PUMP REPLACEMENT /_7 <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> k <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable -Tool - Dia. of.-Well Excavation— <br /> g_ Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation r Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Cone 40 UV <br /> Typelof Pump ,r A H.P. _PA <br /> PUMP REPLACEMENT: /, / ` State Work Done <br /> PUMP REPAIR: ,(; State Work Done , , �-� ,✓ �, <br /> ,DESTRUCTION OF WELL; WellkDiameter Approximate Depth <br /> Desciibe 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 an 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 is true to.the best of my knowle Zael;, eof <br /> SIGNED '(Q Gt_10 - - jar(D W PLOTRSE E <br /> !� FOR MPOTMENT USE ONLY <br /> PHASE I _ <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: a <br /> PHASE II GROUT'IINSPECTIONPHAS III FINAL INSPECTIO <br /> INSPECTION BY ii DATE INSPECTION BY DATE <br /> i <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPEC N. <br /> ` E H 1426 ,. 7/72 IM �+� <br />