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ltnSAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. Hazelton Ave. , Stockton, Cal -fj.' ` ` " TwTy-! <br /> Telephone : (209) 466-6781 // <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMPTPERMIT Permit No. 73 !o O W <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issue L� 7 <br /> (Complete In Triplicate) 257- 270 L <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> This application is made in compliance with San Joaquin <br /> and/or install the work herein described, <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> fl`1!o s• Hoar�E/L� <br /> JOB ADDRESS/LOCATION � ; 2Z432( A X 1L),jfc,.020Q CENSUS TRACT 5� <br /> Owner's Name L„._ Phone <br /> Address R -` l7 vJ N d <br /> _asq, City <br /> Contractor's Name y 9 M „ License // &T Sym <br /> Phone ?F - <br /> TYPE OF WORK (Check): NEW WELL DEEPEN /-7 RECONDITION /-7 DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR /—/ PUMP REPLACEMENT /-7 <br /> Other <br /> 1 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY 4� <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> h <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial y Cable Tool Dia, of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> L IQ <br /> Domestic/public Driven Gauge of Casing �� r <br /> T Irrigation Gravel Pack Depth of Grout Seal �0 <br /> Other Rotary Type of Grout i <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <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 TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE I FOR DEPARTr W§E ONLY <br /> APPLICATION ACCEPTED BYATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION P F AL INSPEC ION <br /> INSPECTION BY DATE INSP ATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />