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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> IOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> __ — Telephone: (209) 466-6781 <br /> r—L APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.73- //60 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued /P_l/•-7 3 <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. 1662 and the Rules and Regulations of the San Joaquin Local. Health District. <br /> I'f JOB ADDRESS/LOCATION .// CENSUS TRACT <br /> Owner's Name 22eov�- Y;, `f•�- "L1 Phone <br /> Address J % �C� /�1 �._.0-Cid . City 02-0 <br /> Contractor's Name License # 37 Pho <br /> 14ZA 2r 2-79 <br /> TYPE OF WORK (Check): NEW WELL J / DEEPEN / / RECONDITION / / DESTRUCTION /-7 <br /> PUMP INSTALLATION /31 PUMP REPAIR REPLACEMENT /- <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SE14ER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER N <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> f Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing .� <br /> Domestic/public <br /> /p Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal. <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done/y <br /> PUMP UPAIR: State Work Donk-s ✓. Gee, C; <br /> .DFsTRUCTION OF WELL: Well Diameter _ Approximate Dep <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health Dist <br /> and the State of California pertaining to or regulating well 'construction. Within FIFTEEN <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health Die <br /> WELL DRILLERS REPORT of the well and notify them before putting the well in use. The abo,' <br /> information is true to the best of my knowledge and belief. <br /> i SIGNED � � :9r r • L ,' x -,) _ TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) ��— <br /> G FOR DF24TMENT USE ONLY <br /> PRASE I <br /> APPLICATION ACCEPTED BY OdnI4C� S . DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION F SE T /FINAL INSPECT " <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 <br />