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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USWby�:made <br /> 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) '466-6781 , <br /> LICATION FOR..WELL CONSTRUCTIO& OR PUMP PERMIT Permit No.-72_,.q <br /> a <br /> THIS``.PERMIT,-EXPIRES.,1..YEAR FROM DATE ISSUED ' 'Date Issued <br /> (Complete In Triplicate) V,; <br /> Application istofthe'San`:Joaquin Local Health District fora permit 'to construct <br /> and/or install the work herein described. This application is made in'+coinplance with San Joaquin <br /> County Ordinance No. 1862 and-.`the'Rules and Regulatiions of'" the San"Joaquin Local .Health District. <br /> JOB ADDRESS/LOCATION _ / qq <br /> CENSUS TRACT <br /> Ph <br /> Owner's Name �; / <br /> L one (P � <br /> Addres's 3 1 , .-City nfsLl-� <br /> i <br /> Contractor's Name License # 118 73 Phone <br /> TYPE OF WORK (Check): NEW WELL /DEEPEN / / RECONDITION /....DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT, /? �I <br /> Other / <br /> � 17G�4 <br /> DISTANCE TO NEAREST: SEPTIC TANK () SEWER LINES PIT PRIVY <br /> } SEWAGE DISPOSAL FIELD _Zj9011- CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE gF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial s Cable Tool Dia, of Well Excavation <br /> Domestic/private I DrilledDia. of Well Casing " <br /> Domestic/public I Driven Gauge of Casing [� . <br /> Irrigation Gravel Pack Depth of Grout Seal 'p <br /> Other Rotary Type of Grout ---- -r— <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor _ <br /> a <br /> Type of Pumpi.� s ` H.P. <br /> t <br /> PUMP REPLACEMENT: /_7 State Work Done f <br /> PUMP REPAIR: _ <br /> / / State Work Done <br /> ESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agre comply with all-laws and regulations of the San Joaquin Local Health District <br /> and th ate -of Ca ornia pert ing or regulating we�l construction.. Within FIFTEEN DAYS <br /> after completion of m work on} ne ell, I will furnishlthe San Joaquin Local Health District a <br /> WELL ILLERS PORT the we 1 a noti y them before putting the well in use. The above <br /> inform tion is true the Is y kn ledge and belief-- <br /> SIGNED <br /> elie SIGNED TITLE ' <br /> i <br /> {DRAW PLOT PLAN ON REVERSE SIDE <br /> F DEPARTMENT'USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED B r �, DATEJ'd Z <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS III FINAL INSPECTION F <br /> INSPECTION BY DATE INSPECTION BY -, DATE /Z <br /> CALL FOR A, ,GROUT INSPECTION#.PRIOR TO GROUTING AND-FINAL INSPECT - • <br /> E H 1426'.: t 7/72 3M <br />