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SAN JOAQUIN LOCAL HEALTH DISTRICT )�7-"l <br /> FOR OFFjI'CE USE: 1601 E. Hazeltori'Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 -73 - 3kS <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.-73 - .3 5 r <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE .ISSUED Date Issued 3 <br /> (Complete In Triplicate) <br /> Application is hereby riade t o'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 San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION XA41 N O 1M O CENSUS TRACT SY 6 <br /> Owner's Name /fQ /J u.7`i�/ Phone <br /> Address._ co2�'; _ �J�/1✓l�'Opts' CityDD-Z — <br /> Contractorts Name J� License #1/7.291 Phonec��r�X33 <br /> TYPE OF WORK (Check): NEW WELL DEEPEN /_/ RECONDITION /-7- DESTRUCTION /7 <br /> PUMP INSTLATION �jt'� PUMP REPAIR / / PUMP REPLACEMENT l�/-7AL <br /> Other ,/ / <br /> f� <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGEIDISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrialable Tool Dia. of Well Excavation <br /> _Domestic/private ! Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing /D-, _Nil <br /> Irrigation 1 Gravel Pack Depth of Grout Seal <br /> 4 Other I Rotary Type of Grout fx- <br /> Other Other Information <br /> ,,PUMP INSTALLATION: Contractor 1E U <br /> - Type of Pump, ' H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: -/. / State Work Done - r _.. _ �..._ .,.� �,� ,,. -v.. 46-. <br /> J)ESTRUCTIONO_F 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 /> information is true to the best of my knowledge and belief. - �-- <br /> SIGNED TITLE /l� ilOR+ <br /> { <br /> DRAW PLOT PLAN ON REVERSE SID <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> - PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE <br /> •7 - _ INSPECTION BY �/ - DATE `. <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />