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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR -OFFICE USE: 1.601 E. Hazelton Ave.., Stockton, Calif. <br /> Telephone: (209) 466--6781 <br /> ,PPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 23 �C <br /> THIS PERMIT,-EXPIRES 1. YEAR FROM, DATE ISSUED Date Issued Y-2-9- 77- <br /> - _ (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 /> -kCounty Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION ... op�v L UcY 's�.ALaNCENSUS TRACT <br /> Owner's Name. b -S mit/C.... ES 'C..fj..I- Phone 6 <br /> Address - ,... City <br /> Contractor's Name License fir` ZZ <br /> Phone <br /> 'HYPE OF WORK (Check) : NEW WELL DEEPEN '/ / RECONDITION /_� DESTRUCTION /_7 <br /> PUMP INSTALLATION/ / PUMP REPAIR/ / PUMP REPLACEMENT /_ <br /> Ocher <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER m <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation M <br /> Domestic/private Drilled Dia, of Well Casing f <br /> Domestic/public Driven Gauge of Casing I" /z <br /> Irrigation Gravel Pack Depth of Grout Seale <br /> Other x Rotary Type of Grout , -- <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor Li't 36 IV, $ ",A L7-,",'At <br /> Type of Pump H.P. / .i <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> i <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 /> 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 /> SIGNED y 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 PHAS III/FINAJO, INSPECTION ; � <br /> INSPECTION BY DATE INSPECTION BY DATE 'j <br /> CALL FOR A GROUT. INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 '"` 4/72 1M <br />