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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif } �� <br /> Telephone: (209) 4666781 w[7` <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. -7340W <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued q -1 Z 3 <br /> ICc , :' (Complete In Triplicate) ©nS 2?O--Z2-_ <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 ADDRESS/LOCATION ,e2 CENSUS TRACT S j <br /> Owner's Name �C'��1 E� '.3 /f" Phone <br /> Address <br /> `' d�F�/•s/�T`rllC /�iGli� v�/�i�GA�u� City <br /> Contractor's Name - 1L r�/GL%f/G _ License # W <br /> _ // � Phone <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN�� RECONDITION DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT 17 <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTjU "M_K_ _.SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL T �- CONSTRUCTION SPECIFICATIONS <br /> Industrial Viable 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 Sealr ar� <br /> Other 1 Rotary Type of. Grout " <br /> `Other Other Information-�r # <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump f2 i� - _ H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: /7/ State Work Done } <br />.RESTRUCTION 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. <br /> i <br /> SIGNED TITLE © ' <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY %J DATE Y-1 7- 7.3_ INSPECTION BY r-/ DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M `- <br />