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JOAQUIN LOCAL HEALTH DISTRIn <br /> FOR OFFICE USE: 16(�E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> PLICATION FOR WELL CONSTRUCTION OR PUMPPFrRMI Permit <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 9'ateV-1sued <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 Joaqu <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local, Health District <br /> EAST Fec•v'r,44C Re•an SouTN of MCIZAOA iu�trr <br /> JOB ADDRESS/LOCATION ,u ,e�,y s�oe CENSUS TRACT <br /> Owner's Name C &e-7-7- ,E -y S f K Phone 931—3 76 <br /> Address 516 SSS~ City STac,1e_7 t_1 i <br /> Contractor's Name � �' •'� `'^":'� `-' ';=< <br /> License # Phone .3 yT/ <br /> TYPE OF WORK (Check): NEW WELL / / DEEPEN /7 RECONDITION J 7 DESTRUCTION /7 i <br /> PUMP INSTALLATION <br /> Other PUMP REPAIR / ./ PUMP REPLACEMENT /7 <br /> / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT 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 <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout . <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor 5A,) Zed uta Atimp Lo, Welk b;- LVAHL t000 as <br /> Type of Pump D P L rsA 7 et z 19 i.u45' ---- H.P. <br /> PUMP REPLACEMENT: / / 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. j <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE)"'..._. _ .. ,. „ ... <br /> OR DEP TMENT USE ONLY <br /> PHASE I Liu:, Ccs fcsr.=a 924 i <br /> APPLICATION ACCEPTED BY DATE t!Z <br /> ADDITIONAL COMMENTS: If <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE 2 p7 G <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 /r/'-' 7/72 IM <br /> 1 <br />