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r, <br /> ,�,s�� •l asr �. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 601 E. Haz$lton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 Y' ' <br /> ICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ��7L A0 <br /> THIS 'PERMIT 'EXPIRE5 1 YEAR FROM DATE ISSUED Date Issued <br /> .(Complete In Triplicate) <br /> Application is herivy 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 Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. ' <br /> JOB ADDRESS/LOCATION -ao , CENSUS TRACT p 6 <br /> Owners Name <br /> ' C Phone fD <br /> + <br /> Address ;. ' ��� City d <br /> j s <br /> Contractor's Name License Phone ,!y' 6'yy_1 <br /> TYPE OF WORK (Check) : -NEW WELL X DEEPEN / RECONDITION DESTRUCTION /? <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT /� <br /> Other <br /> i <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 <br /> Industrial I Cable Tool Dia. of Well Excavation <br /> 0 Domestic/private i Drilled Dia. of Well Casing <br /> 4 <br /> Domestic/public 1 Driven Gauge of Casing <br /> Irrigation + Gravel Pack Depth of Grout Seal 4z <br /> Other Rotary Type of Grout �• C <br /> Other Other Information4rd _41 <br /> f <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR.- / / State-Work Done - <br /> -- - ...,- .._ ._...�_ _ _.;--�.- ,..rte�.r ..,•--�-,:�. --Y <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 /> WEL RS REPORT of the :well and notify them before putting the well in use. The above <br /> info ion true to the best o my. knowledge and belief. <br /> SIGNED TITLE <br /> E (DRAW PLOT ,PLAN ON REVERSE SIDE i <br /> FOR fiEPARTMENT USE ONLY 'JI <br /> PHASE I ;`r„ k <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II :GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE—�7- 7 —INSPECTION BYDATE/p <br /> y <br /> CALL FOR A. GROUT .INSPECTION .PRIOR .TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />