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VZ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. ? <br /> Re2� 9:L� Telephone: (209) 466--6781 7Z- 31 <br /> Q APPLICATION FOR WELT, CONSTRUCTION OR PUMP PERMIT Permit No. _33 /� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued �-2 <br /> pY <br /> �i�( fJ• �`�"'�`�' (Complete In Triplicate) 7VAJ, - <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 /> County Ordinance No. 1862 and the- Rules and Regulations of the San Joaquin Local Health District. <br /> JOB /LOCATION f L jsl,`!e ,fp CENSUS TRACT <br /> Owner's Name d�Y' L u i°til Phone <br /> Address s - /u/r 6 :, City <br /> Contractor's Name N I)Qy Qi75 WCC $'�p11 License �, � Phone�7O- <br /> TYPE OF WORK (Check): NEW WELL )V DEEPEN /_% RECONDITION /__7 DESTRUCTION /_7 <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT /? <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK .SEWER LINES t PIT PRIVY <br /> SEWAGE DISPOSAL FIELD eE& Pe&L/SEEPAGE PIT/d -J- OTHER <br /> ' INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> ' Industrial t---Cable Tool Dia. of Well Excavation <br /> —_ /bomestic/private f—Drilled Dia. of Well Casingfl <br /> Domestic/public Driven Gauge of Casing Z 2- <br /> __A::—Ir.rigation — ..G.ravel.,Pack -- Depth of Grout Seal <br /> Other Rotary Type of Grout i <br /> Other Other Information <br /> i ZL_ d 2 "` / <br /> PUMP"INSTALLATION: Contractor <br /> Wt 0,I/i-cS <br /> Type of Pump T ,` c <br /> _ �(U <br /> PUMP REPLACEMENT: / / State Work Bone � <br /> PUMP REPAIR: / / State Work Dane 1 <br /> ,DESTRUCTION OF WELL: Well Diameter �� � Approximate Depth <br /> Describe Material and Proce ure <br /> I hereby agree to comply with all laws and regulations of the San Jodquin 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 Sari 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. <br /> SIGNED TITLE <br /> DRAW PLOT PLAN ON/REVERSE SIDE) <br /> _....._,.._.FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED- DATE a <br /> ADDITIONAL COMMENTS: <br /> P�ASE II GROUT INSPECTION PHAS NAL INSPECTION <br /> INSPECTION B DATE INSPECTION BY // DATE �2�_ <br /> CALL FOR hROUt��ECTI-ON-PRI-OR-T"ROUTING AND FINAL INS <br /> E H 1426 7/72 IM <br />