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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR.`OFFICfE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> V , Telephone: (209) 466-6781 <br /> APPLICATPRN FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ,L2=0J <br /> i THIS PERMIt'EXPIRES 1 YEAR FROM DATE ISSUED " .,Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> Yand/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 A 4 0 14,LIE CENSUS TRACTj�- s'(� <br /> Owner's dame L. L Phone •- <br /> Address �S S2 �1 - � ° _ City <br /> Contractor's Name `License # /Phorie•_ <br /> TYPE OF WORK (Check): NEW WELL DEEPEN /7 RECONDITION /_77 DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /_ <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER DINES 1§ PIT PRIVY C C <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER 10AIP ., <br /> ' INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation c <br /> __,±:fVomestic/private Drilled Dia.., of Well Casing _ ___ ti <br /> Domestic/public Driven Gaug - of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other -_#4,-'_Rotary Type of Grout <br /> ---- Other . . -Other -Information- - - p <br /> PUMP INSTALLATION: - Contractor,} (� <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 /> informatin is true to the- best-of -my knowledge and belief: - <br /> SIGNED y TITLE42WA F=P --- <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FORAEP T USE ONLY. <br /> PHASE-I _ - - <br /> APPLICATION ACCEPTE Y 7/ -- - 2— <br /> ADDITIONAL <br /> `/ <br /> ADDITIONAL COMME _ _ ._ .. <br /> P I UT INSPECT ON P II NAL INSPECTION <br /> INSPECTION BY DATE — INSPECTI DATE _2-73 <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. e S <br /> E H 1426 7/72 IM <br />