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SAN JOAQUIN LOCAL UEFALT-d DISTRICT eapweL�lg�Ci}y <br /> FOR OFFICE USE: l 1601 E. Hazelton Ave. , Stockton, Calif. a7&�E9D�Sl9G Ld <br /> Telephone: (209) 466-6781 �� <br /> PLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7) _4-144C <br /> ',THIS PERMIT -EXPIRES 1 YEAR Fr OM DATE ISSUED '5T/ 7ate Issued <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 /> Countv Ordinance No. 1362 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION /0 , � = `S, CENSUS TRACT <br /> Owner's Name e tti ,tAA Phone <br /> , �C <br /> Address >��_��=�- aesT t� ICU6. - City <br /> Contractor's Name___j L L r�� �_ License # Phone <br /> TYPE OF WORK (Check): NEW WELLDEEPEN / / RECONDITION / / DESTRUCTION /-7 <br /> PUMP INST TION / / PUMP REPAIR /—/—PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK 7/)r-) SEWER LINES PIT PRIVY 167U <br /> SEWAGE DISP SEAL �i <br /> FIELDo o CESSPO L/SEEPAGE P T OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled_ Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing !U <br /> Irrigation Gravel Pack Depth of Grout Seal > `O <br /> Other _ Rotary Type of Grout <br /> O-thhe--r�-� Other Information <br /> PUMP INSTALLATION: ContractorN f� � (l:l <br /> Type of Pump LS Y� A.P. - i / <br /> PUMP REPLACEMENT: /I' State Work Done <br /> PUMP REPAIR: / % State Work Done <br /> _DESTRUCTION OF WELL: Well Diameter b �� 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 tiff - them before putting the well in use. The above <br /> information is a to the besfof kn edge and belief. <br /> i <br /> c- <br /> SIGNED C. , TITLE Y',, "A- 4 <br /> D PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> Pj3.OSE I <br /> .ICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BYDATE -A yf 'L INSPECTION BY '' DATE .i <br /> CALL FOR A GROUTINSPECTIONPRIOR TO GROUTING AND FINAL INSPECTION. 1�1 <br /> E H 1426 4/72 1M <br />