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1 <br /> SAN JOAQUIN LOCAL,,HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> AP LICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date lssued /3/72' <br /> (Complete In Triplicate) OV-030-10I <br /> Application is hereby made 'to the SanlJoaquin 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 ,e �� ,Ie.Jo0t L� d'1 eo CENSUS TRACT <br /> Owner's Name - I� i�'a�1'da - rz qy •�- �d Phone <br /> I � <br /> Address _(.yob_PA - Sd.wL -T3.4 a, -= - -- City <br /> Contractor°s Name License #/ Phone x- 74;V <br /> TYPE OF WORK (Check). NEW WELL / / DEEPEN / / RECONDITION /_7 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 OTHERfl, <br /> INTENDED USE . TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Too! 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 Grout Seal <br /> Other I Rotary Type of Grout ` <br /> IT Other Other Information„ <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. 3 <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR. °State Work Done <br /> I A� <br /> ,DESTRUCTION OF WELL: Well Diameter Approximate Depth k <br /> Describe`Material and Procedure <br /> i <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.' CL, <br /> SIGNED TITLE <br /> ' (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY '+ <br /> PHASE I- G <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION P I AL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION.-PRIOR TO GROUTING AND FINAL INS 0 j <br /> E H 1426 7/72 1M <br />