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-.SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR aFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> g. APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. _ P <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued.-LI <br /> (Complete` In Triplicate) "T <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 andithe Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 6tAp /1 A?//A WE? 4 �f Qrt. dSy CENSUS TRACT <br /> fV <br /> Owner's Name <br /> I�°"�� "Phone <br /> Address DZ City .S/e P-r 2?114 z x <br /> Contractor's Name �- License #f 7&-J Phone y 767L <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN / / RECONDITION /_� DESTRUCTION /_7 <br /> PUMP INSTALLATION /' (/ PUMP REPAIR / / PUMP REPLACEMENT /? <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 J <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public ' Driven Gauge of Casing <br /> Irrigation I - Gravel Pack Depth of Grout Seal- ' <br /> Other 1 - `Rotary Type of Grout ' <br /> I Other Other Information ` <br /> 1 � <br /> PUMP INSTALLATION: Contractor r p tom, <br /> Type of Pump +ter / H.P. <br /> PUMP &C/ ��State;Work Done ,r <br /> PUMP REPAIR: / / State Work Done <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 <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 krjowle. nd belief. <br /> 3 <br /> SIGNE 'ITLE <br /> (VRAW PLOT. PLAN ON R RSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY = DATE 811L2_7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION. / PHASE III/FINAL INSPECTI N <br /> INSPECTION BY DATEINSPECTION BY AATE <br /> CALL FOR A GROUT INSPECTION. PRIOR_TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />