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P 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 No. 73_-4,,x',3 4. <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED Date Issued _ <br /> (Complete In Triplicate) <br /> kpplication 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 Joaqui <br /> 'ounty Ordinance No. and the Rules and Regulations of the San Joaquin Local Health District. <br /> P18P <br /> JOB ADDRESS/LOCATION CENSUS TRACT /32 (9(Al'C <br /> )wner's Name S12/ R.�1<1L� Phone <br /> lddress �� C City <br /> &- . �(tN <br /> :ontractor'a Name License # t,24 ZPhone 5d, 9.)-2d <br /> .YPE OF WORK (Check): NEW WELL DEEPEN /_7 RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /7 L,a <br /> Other <br /> W <br /> ►ISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY N <br /> SEWAGE DISPOS FIELD CESSPOOL/SEEPAGE PIT OTHER ` <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Ca le 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 Seal <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> UMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> UMP REPLACEMENT: / / State Work Done <br /> UMP REPAIR: / / State Work Done <br /> ESTRUCTION OF WELL: Well Diameter ���� j Approximate Depth 7.2 <br /> e / <br /> Describe Material and Procedur <br /> hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> nd the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> fter completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> ELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> nformation is true to the best of my knowledge and belief. <br /> IGNED TITLE ON'-ku„ <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> RASE I <br /> PPLICATION ACCEPTED BY DATE <br /> DDITIONAL COMMENTS: <br /> PMU II GROUT INSPECTION PHASE,,41jYFININSPECTION <br /> NSPECTION BYDATE INSPECTION BY ATE/ <br /> CALL FOR A GROUT INS P CTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />