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4 SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 73 X33 f <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> ' THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 3-.4"7 <br /> (Complete In Triplicate) 96 - 07d -0 / ` <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 Joagi <br /> County Ordinance No. 1862 and the Rules and Regulations of the�(5 (S//ann Joaquin Local Health District <br /> "7S1• �=+��u � � /� . CENSUS TRACT <br /> -JOB ADDRESS/LOCATLON Cp A_T �J7 Y) /� -"�� c �• ' �' <br /> J <br /> j „ J �C� <br /> Owner's Name Phone <br /> " -- <br /> Address 71i' � � ' City/ <br /> ,'� ? n_, License # 12,(f.n Phone Z - <br /> Contractor' s Name O* �''` _ <br /> TYPE OF WORK (Check) : NEW WELL /_/ DEEPEN /� RECONDITION /-T DESTRUCTION / <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other / / _. --. <br /> DISTANCE TO NEAREST- SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/ C,-li �IT OTHER <br /> .j� ,�`c+7:; Jc �r�_ 7h ,/' <br /> INTENDED USE USE PE OF ELL CONSTRU ION SPECIFICATIONS <br /> Industrial <br /> 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 <br /> Type of Pump <br /> 7/ a= /•Jl <br /> PUMP REPLACEMENT: / / State Work Done &mac61 �s� / <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 Distric <br /> and the State of Californiapertaining to or regulating well construction. WithinFIFTEENDA) <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health Distri( <br /> WELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> information i true to thelbept of my knowledge and belief. <br /> SIGNED J ' cQ '� TITLE <br /> (D k' PLOT PLAN ON REVERSE SIDE <br /> II FOR DEPARTMENT USE ONLY <br /> PHASE I { / /� DATE <br /> APPLICATION ACCEPTED BY Illi <br /> ADDITIONAL COMMENTS: PHASE II /FINAL INSPE TION <br /> PHASE II GROUT INSPECTION DATE - 'Z3 <br /> INSPECTION BY ? DATE INSPECTION BY - " • . <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTIONrg <br /> / ✓� /" '- 4/72 1M <br /> F. H 1426 ! n .,r�i i /fill�Yt•'�"-C1- Vii`' <br />