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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. 73 1 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> pplication is hereby made to the San Joaquin Local Health District for a permit to construct <br /> nd/or install the work herein described. This application is made in compliance with San Joaquii <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> OB ADDRESS/LOCATION �3 AlV Pe , � CENSUS TRACT <br /> Owner's Name y- '' f Phone <br /> address e{1_4 �� �, ,g � !r't City "O-d ts� <br /> T <br /> ontractor's Name , License #//� 1-,!Phone 4� l 24� per; <br /> i <br /> -YPE OF WORK (Check) : NEW WELL / / DEEPEN /_/ RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR /g(/ PUMP REPLACEMENT /_7 <br /> Other / / <br /> ISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS v <br /> Industrial Cable Tool Dia, of Well Excavation (' <br /> 1r 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 <br /> Type of Pump u H . <br /> PUMP <br /> PUMP REPLACEMENT: / / State Work Done <br /> 1 � r <br /> JMP REPAIR. / / State Work Done /-; ,4 c ePC f <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 /> id the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> :ter 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 /> fzformation is true to the best of my kn wledge and belief. <br /> SIGNED.• / 3:,. _ -TITLE r-6__f <br /> (D •W PLOT PLAN ON REVERSE SIDE) <br /> t- FOR DEPARTMENT USE ONLY <br /> ,.MASE I <br /> APPLICATION ACCEPTED BY DATE �j- ')3 <br /> )DZTIONAL <br /> COMMENTS: - <br /> PHASE II GROUT INSPECTION PHASE I I/FINAL INSPECTION <br /> INSPECTION BY a DATE INSPECTION B _ DATE 7� <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPE TION. <br /> E H 1426 W 7/72 1M <br />