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f�Z1601 <br />SAN JOAQUIN LOCAL HEALTH DISTRICT <br />FOF.:OF ICE USE: E. Hazelton Ave., Stockton, Calif. <br />Telephone: (209) 466-6781 <br />APPLICATION FOR WELL CONSTRUCTION OR 'PUMP PERMIT <br />FILE COPY <br />Permit No' %lSN r.J <br />THIS PERMIT FIRES 1 YEAR FROM DATE ISSUED Date Issued 1-20-76 <br />�y,A19gWete In Triplicate) <br />Application is hereby made to the an 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 Jpaquin <br />County Ordinance No. 1862 and the.Rules and Regulations of the San Joaquin Local Health District. <br />JOB ADDRESS/LOCATION CENSUS TRACT, <br />�y. r <br />Owner's Name` ..,- _Un .4 C 44Z Phone <br />Address <br />City <br />Contractor's Name <br />License <br />TYPE OF WORK (Check): <br />NEW WELL DEEPEN /_7 RECONDITION// DESTRUCTION /_7 <br />` <br />PUMP INSTALLATION j / PULP REPAIR'/-7—PUMP REPLACEMENT /? <br />Other / % <br />DISTANCE TO NEAREST: <br />SEPTIC TANK SEWER LINES PIT PRIVY <br />[s <br />` <br />SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br />^0 <br />INTENDED USE <br />TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br />fi <br />Industrial <br />'' Cable Tool' Dia. of Well Excavation <br />Domestic/privateN <br />1rDrilled Dia. of Well Casing <br />--)(Driven <br />Domestic/public <br />Gauge of Casing <br />Irrigation <br />Gravel Pack Depth of Grout Seal <br />OtherRotary <br />'k Type of Grout <br />=40ther <br />Other Information <br />PUMP INSTALLATION: <br />Contractor <br />[!� <br />Type of Pump H.P.. <br />PUMP REPLACEMENT: <br />/7 State. Work Done <br />PUMP 'REPAIR: <br />/%, State Work Done <br />;DFSTRUCTION OF WELL: <br />Well Diameter Approximate Depth <br />Describe Material and Procedure <br />I hereby agree to comply <br />with all laws and regulations of the San Joaquin Local Health District <br />and the State of Calif <br />oruia pertaining to or regulating well'construction. Within FIFTEEN DAYS <br />after completion of my <br />work on a new well, I will furnish the San Joaquin Local Health District <br />a. <br />14ELL DRILLERS REPORT of .th& well and notify them before putting the well in use. The above <br />information is true to <br />thembest of my knowledge and belief. <br />SIGNED - TITLE <br />(DRAW PLOT PLAN ON REVERSE SIDE <br />r R DEPARTMENT USE ONLY <br />PHASE I , <br />APPLICATION ACCEPTED .BY DATE <br />ADDITIONAL COMMENTS: <br />PHA II kRO11T INSPECTION PHASE III/FINAL INSPECTION <br />INSPECTION BY.. DATE 2 INSPECTION BY DATE <br />CALL FOR A.GROUT INSPECTION PRIOR TO-GROUTING,AND -FINAL 'INSPECTION. <br />E H 1426 <br />'%. 31M <br />