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SAN .JOAQUIN LOCAL REALTH DISTRICT <br /> FOR OFFICE USE: 1 1j EW A"c elton Ave. , Stockton, Cali <br /> Teleph�bn'e: (209) 466-6781 f <br /> AT,I,O OR WELL CONSTRUCTION OR PUMP IT ermit No. 7 L. 6 <br /> THIS,__?TW7.L_ &PTRES 1 YEAR FROM DATE ISSUED Date Issued K. Z a. Z <br /> -ACTH MSTRIO Mmplete In Triplicate) <br /> Application is hereby .indde to the­San 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 Q4 <br /> CENSUS TRACT <br /> , = <br /> Owner's Name ° + ' ; Phone r7 9 91 <br /> Address ? / City J <br /> Contractor's Name License # j_ 7ti3 Phone <br /> TYPE.OF WORK.-.(Check) : NEW WELL / / DEEPEN /_./ RECONDITION /_/ -DESTRUCTION /� yA -� <br /> PUMP INSTALLATION ./ / PUMP REPAIR PUMP REPLACEMENT /-7 <br /> Other / / — <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> �f <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 /> PUMP INSTALLATION: Contractor <br /> Type of Pump . H.P. <br /> PUMP REPLACEMENT: J / State Work Done <br /> PUMP REPAIR: State Work Done <br /> . T <br />:DESTRUCTION OF WELL: Well Diameter ww Approximate,Depth- -ti_._-_ _ <br /> Describe Material and Procedure i <br /> a <br /> M <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 notifythem before putting the well in use. The above <br /> p g 1 <br /> information is true to the best of my knowledge and belief. <br /> SIGNED J 4 TITLE <br /> (DRAW PLW OLAT4 ON REVERSE SIDE <br /> FOF, 1APARTMENT USE ONLY <br /> PHASE I f ` <br /> APPLICATION ACCEPTED BY _ DATE tv � )7 2-- <br /> ADDITIONAL <br /> ADDITIONAL COMMENTS: <br /> PHASE IT GROUT INSPECTION PHASE III/FjNAL INSPECTION <br /> INSPECTION BY DATE INSPECTION B DATE. , 21-4F tl <br /> .�z— <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 4/72 1M <br />