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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR Of CE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. -7y/6 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (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 Rules and Regulations of the San Joaquin Local Health District. <br /> ,TOB ADDRESS/LOCATION . � <br /> Y-c CENSUS TRACT <br /> Owner's Name LJ t L l cc f C 47-GLa� Phone <br /> Address 2 City (fA:rC4M—, <br /> Contractor's Name License #/ 3 7--r_Phone74 <br /> I <br /> TYPE OF WORK (Check): NEW WELL /_7 DEEPEN /7 RECONDITION /_7 DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR g/ PUMP REPLACEMENT /_7 <br /> Other / / <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 1- <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal - 1 <br /> — — Other Rotary Type of Grout <br /> _ Other Other Information <br /> a <br /> i <br /> PUMP INSTALLATION: Contractor cs:�aJ g-L <br /> I <br /> Type of Pump _ m f, H.P. <br /> PUMP REPLACEMENT: / J State Work Done- <br /> PUMP REPAIR: / State Work Done � 07,0 <br /> _. <br /> ESTRUCTION 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 I <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 is true to the best of knowled e- nd belief. <br /> 1 <br /> SIGNED � ✓ TITLE /'A V - ' <br /> ( RA PLOT PLAN ON REVERSE SIDE I <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FI INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY43 DATE z f <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECT <br /> E H 1426 7/72 1M <br /> i <br />