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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 4 FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 46q-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. � <br /> k 941,- 171�° a <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued L-- BZy <br /> (Complete In Triplicate) <br /> Application is hereby 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 Heal h District. <br /> � c 330- <br />' JOB ADDRESS/LOCATION _�-`�h.� �A �S'A �' ------.--- CENSUS TRACTy <br /> OwnersName Phone <br /> 36 4?- 7 7/3 <br /> Address �� lo� �. L.1 a-�.s�.�.�" Jt -- City <br /> Contractor's Name License V,/ -2373 PhonJ <br /> �-TYPEYOF-WORK Y(-Cheek):—NEW-WELL:,��DEEPEN/--7—RECONDITION-/-7---;-DESTRUCTION-/ <br /> PUMP INSTALLATION jQ PUMP REPAIR / / PUMP REPLACEMENT / T <br /> M Other /-7 ZA <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 y y� Cable,Tool.--- ..., .Dia.- of Well- Excavation � 14e•,' <br /> Domestic/private Drilled Dia.` of Well Casing /feI <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal -� <br /> Other Rotary Type of Grout <br /> Other - Other Information <br /> i <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. 1 . <br /> PUMP REPLACEMENT: / / State Work Done <br /> -_ <br /> PUMP REPAIR: / / State Work Done <br /> pESTRUCTION OF WELL: Well Diameter _ T Approximate Depth <br /> Describe Material and Procedure <br /> i 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 /> i <br /> SIGNED TITLE <br /> i RAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> 3 <br /> APPLICATION ACCEPTED BY M DATE `S `7 <br /> ADDITIONAL COMMENTS: <br /> PHASE 11 GROUT INSPECTION PHASE IU/FIZJAL INSPECTION. <br /> INSPECTION BY DATE INSPECTION BY i' - DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />