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V, '\�4�a1SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> A Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. .72426 <br /> 2(o <br /> \ THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> �4,J�' (Complete In Triplicate) <br /> Application s hereby �ade 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 /> JOB ADDRESS/LOCATION ff d�s Q CENSUS TRACT <br /> Owner's Name 14) 0-r it-t-_1 ly.AJ Phone t z0, y3e <br /> Address - -� .� 00-) City ,. <br /> Contractor's Name License Phone T_4 <br /> TYPE OF WORK (Check): NEW WELL / / DEEPEN /_7 RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR /r--/ 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 �+ <br /> Domestic/private Drilled Dia. of Well Casing +�� <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> A <br /> PUMP INSTALLATION: Contractor JL ►�(.� <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> „DESTRUCTION 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 of my knowledge and belief. <br /> SIGNED R�..., ,,.� `nj . �j� y ,z z_ ��.�-,Lp TITLE am <br /> (DRAW PLOT PLANION �RE`V`E'RSE SID <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I L . <br /> APPLICATION ACCEPTED BY 1�1 DATE f� <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BYDATE /p Ind <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSP _ ON. <br /> E H 1426 7/72 1M GOD— <br />