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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone,: . (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION' OR PUMP PERMIT Permit No. Z ({j <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED. Date Issued/ Q_-//72 <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct <br /> and/or install the work herein described. This application is made in compliance iiith San Joaquin <br /> County Ordinance No. 1862' ind the Rules and .Regiilations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION _�rv 'LL3 .s'. xa.N� i xIGRS FereA uaLL NJ?A�- e� CENSUS TRACT <br /> AtC./ <br /> sO Y! <br /> Owner's Name _f _ M L Sid 01 L Phone <br /> Address LILL . t i City T e / d nl <br /> � _-__ ty <br /> $&L, 3(16aa <br /> Contractor's Name 6 ly ty L' RD License # o Z i Phone _t2k •?j'�2� <br /> TYPE OF WORK (Check) : NEW WELL A/ DEEPEN /_/ RECONDITION /_7 DESTRUCTION /_ <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /_ <br /> Other /_7 <br />• DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY W <br /> SEWAGE-DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial x Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing _z4ft j ,'H J , L-. <br /> Domestic/public Driven Gauge of Casing jj.� S <br /> X Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> } <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: /7 State Work Done <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 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 /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 10161, <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PRASF,%III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECT N. <br /> E H 1426 7/72 IM <br />