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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 0 "r,ICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No..77-11- &1� <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED Date Issued -28=73 ' <br /> (Complete In Triplicate) 2 4) ? - -3v <br /> Application is hereby spade 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 Joaquin <br /> County Ordinance No. 1862-and the Rules and Regulations of the. Sari Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION '` TRACT ' <br /> k <br /> Owner's Name E I-L- <br /> Phone <br /> Addressir 7 ` City r f <br /> 1 - a License �E1� Phone <br /> Na <br /> Contractor s ;m-e IL ILO, <br /> TYPE OF 451 i (Check CONDITION/—/ DESTRDCTION /-71" <br /> PUMPAL <br /> INSTLATION / / PUMP REPAIR / / PUMA.' REPLACENT 1-7 � <br /> Other ./ /i s <br /> DISTANCE'TO NEAREST: SEPTIC TANK _ SEWER LINES PIT PRIVY #. <br /> ' jj SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> f 4 <br /> INTENDED USE r`" - TYPE. OF WELL CONSTRUCTION SPECIFICATIONS <br /> �� <br /> Indutrial Cable Tf Dia. of Well. Excavation <br /> o <br /> D'otaestics /private Drilled Dia. of Well. Casing fca�/ -`_- <br /> _ Domestic/public I Driven Gauge of Casing S /' \^- <br /> f V Irrigation �,' Gravel Pack Depth of Grout Seal <br /> ' Other �� Rotary Type of Grout -' <br /> Other Other Information <br /> i� PUMP INSTALLATION. Contractor <br /> i -- Type of Pump-_ . H.P. `r <br />`t PUMP REPLACEMENT: State Work Done <br /> k PUMP `tEPAIR: / / State Work Done <br />+ DFQTRICTION OF WELL: Wel.l' Diameter Approximate Depth <br /> �r Describe Material and Procedure <br /> I hereby agree to comply with all laws afil regulations of the San Joaquin Local Health District <br /> and the _5tate 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 /> s{ information is true to the best oft my knowledge and belief. <br /> TITLE <br /> 'rk SIGNED &A/s.A 21-A <br /> ED PLOT PLAN ON REVERSE SIDE) <br /> li <br /> FOR DYRAFTNENT USE ONLY <br /> A-PP3.ICATION-ACC'EPTED- 64� - --�-�- - ��DAT.E �-` / - <br /> ADDITIONAL CO: NTS: ' <br /> PHASE II GROUT INSPECTION " PHASE III/FINAL INSPECTION <br /> ,. <br /> ` INSPECTION BY DATE /0`wZ 9 <br /> INSPECTION BY DATE <br /> ' CALLkFOR A GROUT INSPECTION' PRIOR TO GROUTING AND FINAL INSPECTION. <br /> -- _ ..._ 5/731M <br />