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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> f'OR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> I Telephone : (209) 466-6781. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> Zg- <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date. Issued /-x_23 <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 Joaqui <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> r <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name Phone _ ��,� 39 <br /> Address 117 . 4 ' 1140e City - - <br /> Contractor's Name -License # /�9y� hone y 7jg 74 <br /> t E lE° <br /> TYPE OF WORK (Check) : NEW WELL /-7 DEEPEN / / RECONDITION /-T DESTRUCTION /_7 <br /> PUMPjINSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT I)_e7 <br /> i Other /_7_ <br /> r � -- <br /> E <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 Cable Tool Dia. of Well Excavation v <br /> Domestic/private Drilled Dia. of Well Casing -C <br /> Domestic/public ! Driven Gauge of Casing <br /> ` Irrigation x I Gravel Pack "Depth "of Gout Seal <br /> �C Other t. Rotary Type of Grout <br /> Other Other Information a <br /> PUMP INSTALLATION: Contractor <br /> Typeof Pump ` H.P. <br /> i <br /> PUMP REPLACEMENT <br /> 49/ ' State Work Done <br /> 497 <br /> 24± ZZ A6 <br /> PUMP REPAIR- / / State Work Done <br /> ,DESTRUCTION .OF WELL: Well�Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply Frith 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 1 true to the best of my kno edge .and'"be ef. <br /> SIGNED <br /> (DRA P T PLAN ON REVER IDE <br /> DEPARTMENT USE ONLY <br /> ► PHASE I <br /> APPLICATION ACCEPTED BY DATE T,� - <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS III FINAL INSPECTION <br /> INSPECTION BY DATE `INSPECTION BY DATE 16 3 <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECT19. <br /> E H 1426 7/72 IM � " <br />