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lY-pj <br /> m. dOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: `l 'A a E. Hazelton .Ave. , Stockton Calif. <br /> r Td1ephone: (209) 466•-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 3 '177 <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED Date Issued3 <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> and/or install the work 'herein- desaribed. 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. /.15r,`6 a A pGIV CENSUS TRACT <br /> Owner's Name E,944 S 7 R AG1��3 .__ Phone 14.6 1/ 4j > z/ <br /> Address E 576 hf•.._,...��.,Q ., <br /> - „_„_...._ ._..._.__. City S T/<-/V' <br /> Contractor's Name License # z6 t Phone 4rCe 36 <br /> TYPE OF WORK (Check) : NEW WELL /? DEEPEN / / RECONDITION /_7 DESTRUCTION /_ <br /> PUMP INSTALLATION /—/ PUMP REPAIR / / PUMP REPLACEMENT k <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 V� <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 s <br /> Type of Pump H.P. 2- <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> 7 <br /> ESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> i <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 ,�- yo ¢ l, . ie-Qc TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE I FOR DEPARTMENT USE ONLY ; <br /> APPLICATION ACCEPTED BY t DATE 3 <br /> ADDITIONAL COMMENTS: <br /> PHASE If GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY - — _ DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 IM <br />