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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ' FOR 'OFFICE USE: 1601 E. Hazelton" 'Ave:°,' Stockton, Calif. I 1 <br /> Telepk66_0;.° (209)```4'66-6781 I <br /> APPLICATION FOR .WELLA•'CONSTRUCTION'OR PUMP PERMIT Permit No. 3- tS <br /> THIS'PERMIT°'EXPIRES' l, FROM DATE ISSITEDDate Issued . <br /> rO 4.}:./ d 3 - - I � .✓ Y[ :•0.L 1 d .73 .. <br /> (Complete .In'Triplicate) -; - <br /> Application `is .hereb'y oracle to' the 'Saiz `Joaqufn'Local- Health bistrict '%`r `ape¢rm 't to construct <br /> and/or install the work herein described. 'Thins application is niade*'in Compliance' with` San Joaquin <br /> County, Ordisiance No' 1816Z' an`d' the {Rules `and Regulations of"the Sar; `JoaquinI;ocal Health' District. <br /> 1.kf.&-d.ry1i { i,;w '� ♦� . _.eJ ;0....1r f.(: l., � 'hf' .r t ..�/,1 1- .s YrV .1 4.1.Ty q .. .!- .I'. <br /> JOB ADDRESS/LOCATION .t ,r <br /> f .{. r. . , 3 :.p . .� . ,. _ . CErrsus TRACT <br /> Owner's, Name <br /> Ph one Ot. <br /> Address Cit <br /> Contractor's Name � License ��,f-��Phone <br /> i <br /> TYPE OF WORK (Check) : NEW WELL / / . DEEPEN /_7 RECONDITION /7 DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR '/—/ PUMP REPLACEMENT - <br /> Other <br /> E <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER � <br /> i <br /> INTENDED :USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS 1 <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 F Gravel Pack Depth of Grout Seal � <br /> Other t Rotary Type of Grout <br /> Other . Other Information <br /> PUMP INSTALLATION: Contractor e, (� "�+ <br /> 'Type, ofj Pu H.P. <br /> PUMP REPLACEMENT: / / ` State Work Done r <br /> PUMP REPAIR: / / State Work Done f <br /> ESTRUCTION OF WELL: Well Diameter '' <br /> - -- .. Approximate Depth <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 StateLof California pertaining to or regulating well construction.. Within FIFTEEN DAYS <br /> after completion of my workon'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 e. best of my knowledge and belief. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE -Z <br /> ADDITIONAL COMMENTS: 74" A/XV 41 <br /> PHASE II GR U SPEC IO PHAS I I/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> I <br /> CALL FOR A GROUT-INSPECT.ION::PRIOR:TO GROUTING AND FINAL INSPECTI - - <br /> E H 1426 7/72 1M <br />