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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , 'Stockton, Calif. <br /> Telephone: (204) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.73-- 384.2 yP <br /> ` THIS PERMIT EXPIRES 1- YEAR FROM DATE ISSUED Date Issued z-3 <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 described. This application is made in compliance with San Joaqui <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> brio rss� <br /> JOB ADDRESS/LOCATION LVl9(� 4, �` f Z D`��� � _�� CENSUS. TRACT <br /> Owner's Name 5 r Phone.,tr <br /> Address _4100 4 GCity <br /> Contractor's Name _ z!�___V_�- , License #�6S;x(�Phone <br /> TYPE-OF WORK (Check): NEW WELL DEEPEN / / RECONDITION' / DESTRUCTION /_7 -� <br /> PUMP INSTALLATION / / PUMP REPAIR /,V PUMP REPLACEMENT /? <br /> Other /_7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE E <br /> TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial. 1 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 /> f Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> k Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR. State Work Done 6 <br /> , ,pESTRUCTION 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 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 <br /> TLE 4- cn, . <br /> ( L4 PLOT ON REVERSE SIDE <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> . APPLICATION ACCEPTED BY DATE <br /> tADDITIONAL COMMENTS: <br /> PHASE II GR UT INSPECTION .PHASE III FINAL INSPECTION <br /> NSPECTION BY . DATE � INSPECTION BY <br /> DATE - - <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M "'"� <br />