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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR-OFFICE USE: 1601 E. Hazelton, Av'e.',.-Stockton, Calif. <br /> Telephohe: — (209)---`4666781 <br /> PLICATION FOR WELL CONSTRUCTION- OR PUMP PERMIT Permit No. 7Z-- 6, 5 <br /> THIS PERMIT •EXPIRES .1 YEAR1FROM DATE ISSUED Date Issued 7 3 7 2-- <br /> (Complete lh'-Triplicate) <br /> Application �is -her ima eito th&a,SanjJbaquin,' LocAl Health District for a permit to construct <br /> and/or install the work -herein described. This: apnllcation 'is made in compliance with San Joaquin , <br /> County Ordinance No1862,..and.,,th&...Ru, si "', nd ".Regul , --the- San Joaquin Local Health District. <br /> ".Regula oy <br /> JOB ADDRESS/LOCATION 16 CENSUS TRACT ' 00 ,(- Z30,2.0: <br /> Owner.'s Name ci- Phone <br /> Address City <br /> Contractor's Name License # <br /> Pho fi e <br /> yp <br /> TYPE OF WORK (Check) : NEW .WELL DEEPEN _-RECONDITION'f_/ DESTRUCTION /_7 <br /> PUMP INSTALLATION PUMP REPAIR PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL .FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> Q <br /> INTENDED' USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial 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 GiZ�ut Seal <br /> Other Rotary Tjpe, of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: State Work•,D8ne <br /> PUMP REPAIR: State Work Done oazl, Q.4 A <br /> ,DESTRUCTION OF"i4_Iff M.7 Well_1D1_aMJter p <br /> _X1 p-r_om a R-1 e <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 regulatingrwell cp--nstruction. 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 tru'e. to. the best of my knowledge and belief. <br /> SIGNED �4 <br /> Aar& jl._jl TITLE <br /> (DRAW- KEV- <br /> PLOT/PX ON ERSE SIDE4� <br /> ,��R EP�RT7T USE ONLY <br /> PHASE I I ON <br /> APPLICATION ACCEPTED BY 4Lt_Ziott - DATE <br /> ADDITIONAL COMI-MNTS: <br /> PHASE II GROUT INSPECTION PHASn 1114FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE 6 <br /> CALL FORA GROUT INSPECTION-PRIOR-TO.-GROUTING,AND FINAL INSPECTION. <br /> E H 14,26 4/72 1pft <br />