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SAN -JOAQUIN LOCA. ?, : LTH. DISTRICT <br /> FOR OFFICE USE: 1501 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: '- (2091 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR. PUMP PERMIT Permit No. ]c/ <br /> THIS PERMIT EXPIRES 1, YEAR FROM. DATE ISSUED , Date Issued <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 with San- Joaquin <br /> County Ordinance -No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 7 7 CENSUS TRACT ' <br /> Owner's Name i 9 1 C_ Phone <br /> t Address S �f '7 . V' City <br /> �} <br /> Contractor's Name Ley �V s � License Phloon�e . <br /> gq,!�-3.�S <br /> TYPE OF WORK (Check) : NEW WELL -/DEEPEN -/-7 RECONDITION /_7 DESTRUCTION /_7 - <br /> PUMP INSTALLATION/Ur PUMP REPAIR/ / PUMP REPLACEMENT /? <br /> Other / J <br /> ' DISTANCE TO NEAREST: SEPTIC TANK,/_0 SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER U <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation 1143 If <br /> �omestic/private Drilled Dia. of Well Casing <br /> 'Domestic/public Driven Gauge of Casing 3 <br /> Irrigation ravel Pack Depth of Grout Seal 56 +- E4- <br /> Other [/~Rotary Type of GroutSlu�r,c- <br /> Other Other Information <br /> °TUMP INSTALLATION: Contractor <br /> Type of Pump H.P. - <br /> r <br /> PUMP REPLACEMENT: / / State Work Done <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 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 l TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED EX DATk <br /> ADDITIONAL- COMMENTS: <br /> PHASF�,II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E HL <br /> 142R GROUT GINSPECTION�/ 0��TO GROUTING r ,FINAL IN4/72 iM <br />