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-rw 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 <br /> 73 - .237p <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -9= 73 <br /> i (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 Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> 40B ADDRESS/LOCATION ' D 7 CENSUS TRACT <br /> 3 � <br /> 'Owner's Name Phone39-7064x& <br /> Address 0 CJ t' S: iii�- fug QkL __ city _,ES�A _._ <br /> I <br /> Contractor's Name f License lP�� Phoney <br /> TYPE OF WORK (Check) ; i NEW WELL _7-, DEEPEN _/ MP,RECONDITION /�� DESTRUCTION <br /> ' PUMP INSTALLATION PUREPAIR / / PUMP REPLACEMENT <br /> 4 <br /> Other� <br /> k DISTANCE TO NEAREST: SEPTIC__TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED- USE- -TYPE OF-WELLCONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia.- 'of Well Excavation C <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 ofGrout <br /> Other, Other Information <br /> PUMP INSTALLATION; y' Contractor <br /> Type� of Pump _ H.P. f <br /> PUMP REPLACEMENT: _ / /,; SCate Work Done <br /> PUMP REPAIR --";-��V*_Statie'Work Done <br /> 1 ,DESTRUCTION OF WELL: Well Diameter 7 Approximate Depth Q � <br /> S. Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations o£ 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. <br /> 00 <br /> SIGNED TITLE <br /> (DRAW_ PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT °USE ONLY <br /> PHASE I ATE 3 <br /> APPLICATION ACCEPTS Y <br /> ADDITIONAL CO <br /> OUT INS—P% 10 P F AL INSPECTI a <br /> INSPECTI BY DATE °� .. INSPECTI BY ATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> 7/72 IM <br /> E H 1426 '` <br />