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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> , `FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> :I Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 73 !o O <br /> THIS PERMIT EXPIRES 1 YEAR FROM' DATE ISSUED Date Issue 7.5 <br /> (Complete In Triplicate) 25 7r 270 Z <br /> Application is hereby madelto the San Joaquin Local Health District fora 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 CENSUS TRACT <br /> Owner's Nage Phone s-93;p_ <br /> Address <br /> ' may, City. <br /> Contractor's Name a License # ,2V Phone 7 -,>Gi <br /> TYPE OF WORK (Check) : NEW WELLZT DEEPEN /_% RECONDITION /_7 DESTRUCTION /_ <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /_ <br /> Other <br /> 1 4 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> h <br /> INTENDED USE TYPE. OF WELL CONSTRUCTION SPECIFICATIONS �j { <br /> Industrial_ . y Cable. Tool Dia-.r-of-Well Excavation <br /> _...�._ .. a, .. <br /> Domestic/private il �t„ : .Y Drilled Dia. of Well Casing ' b <br /> Dome-s•tiC/pubri�7,'1"'"'"'”- —Driven '- Gauge of Casing <br /> 16 oil, <br /> - Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of !Grout <br /> Other Other Information <br /> .i <br /> A <br /> PUMP INSTALLATION; Contractor j { u , <br /> k <br /> Type of Pump _ H.P. <br /> PUMP REPLACEMENT: / / State Work Done F �: <br /> PUMP .REPAIR:<- -----_ . .� <br /> -� /�/�S•ta-te�Work-Bone <br />,DESTRUCTION OF WELL: 'Well Diameter <br /> 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,,FIFT 'Ek 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 qj, <br /> _ � -.�-� , TITLE <br /> (DRAW PLOT• PLAN ON REVERSE SIDE <br /> FOR-.DEPARTMAWNTr <br /> & ONLY # <br /> PHASE I <br /> APPLICATION ACCEPTED BY ATE <br /> ADDITIONAL COMMENTS: <br /> 11f Y/ <br /> PHASE II GROUT INSPECTION P F AL INSPECTION <br /> INSPECTION BY DATE INSP ATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 IM <br />