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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OF CaE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> I� Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED Date Issued 3_Z2 <br /> k (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 Ornance Na. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br />• � �%t1i•Pf/�Oy/) � <br /> JOB ADDRESS/LOCATION CENSUS 'TRACT <br /> owner's Nme Phone <br /> Address City S- 7_0ar Cll r. <br /> Contract Name LZ Z]e/� IAA 4 _�----L' _%�/ /;� �F License �� �( Phone ,Z � <br />' TYPE OF WORK {Check) : NEW WELL /f� DEEPEN / / RECONDITION /� DESTRUCTION /� <br /> i PUMP INSTALLAT+ION / / PUMP REPAIR / / PUMP REPLACEMENT J7 <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 /> Inddstrial Cable Tool Dia. of Well Excavation 4.: <br /> Domestic/private Drilled Dia, of Well Casing -_ - , 1�. <br /> Domestic/oublic Driven Gauge of Casing 2 <br /> Irrigation 1 Gravel Pack Depth of Grout Seal AL1 _ <br /> Othe`r' i Rotary Type of Grout <br /> 1 Other Other Information <br /> PUMP INSTALLATION: Contractor 5 j JA//I �, . T U C U <br /> ff I Type o f PisMP _ /"l f� f?a 113 - -- H.P. <br /> PUMP REPLACEMENT: State Work Done" /T <br /> PUMP REPAIR: / / State Work Done <br /> ,DESTRUCTION OF WELL: Well Diameter Approximate Depth ? <br /> Describe Material and Procedure = /r7, <br /> I hereby tree. <br /> to comply with all laws ind 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 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 my knowledge and belief. <br /> 11 <br /> SIGNED - TITLE 4/ l.. le <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> i/ FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED IkY DATE7 3 <br /> ADDITIONAL COMMENTS: <br /> + P GROUT NSPECTION" 7 PHASE FINAL INSPECTION <br /> INSPECTIO�r BY DATE . ��f 7 ' INSPECTION-BX DATE 3 <br /> CALL FOR INSPECTION PRIOR TO GROUTING AND FINAL INSPECTI <br /> E H 1476 7/72 IM "° <br />