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i <br /> SAN JdAQUIN LOCAL HEALTH DISTRICT , <br /> FOR OFFICE USE: 1601 E. Hazelto:i-Ave.-,;Stockton, Calif. <br /> Telephone: (209) '466.'6781" <br /> APPLICATION FOR WELL CONSTRUCTI:ON:`,O PUMP PERMIT Permit No. 7,2-1 �U <br /> THIS PERMIT:.-EXPIRES 1.YEAR;FROM:DATF ISSUED Date ,Issued <br /> . F :7 .(Complete •Ift Ttiplit.at:e) <br /> ApplicationL,isn.iherebyi:mades.to 'the::>;San J,oaquin�_-Local .Ii6alth District.`.for',a''pe init:°to'-cons`triie't <br /> and/or install the work herein described. This-applxic-ationl `s-madam:in i compliance' with. Sangi Joaquin <br /> County:F,Ordina'nce;,,NoX,1862°andL,the.� Ru_.ies-andr-Regulvtkons-.bf�1:the.:8au-`.Joaquin`Local'?Heal thlDistrict. <br /> r�< f,IJ�f 1 O'y3 rt 11ei •7 <br /> 0 , f (• } <br /> Fy- „.<';• C:C rj .. t., is a. ,..�k..•'.da 's J <br /> JOB ADDRESS/LOCATION "�- - CENSUS-%TRA.CT,,S`.t,1;js <br /> �C•. fS' '1,01,1310.:0 rpt �-`fT- .�.?',: s.l i f \ '.i _ `3srJ t,'vf «.' :9's+ <br /> Owner'S'3 Na e;.; sV , Phone` �Q'� � 'I r A <br /> r <br /> C/ <br /> t Address 9CI <br /> f 1\_ M--I - �. .- City . c°. .� <br /> Contractor's Name 5�mr-y License #/ Z„(;�>Phone q--7 <br /> TYPE OF WORK (Check): NEW WELL/�EPEN /_7 RECONDITION / / DESTRUCTION /_7 <br /> ' PUMP INSTZLATION / / PUMP REPAIR / / FUMP 'REPZACEMENT /� ; <br /> Other, ./ ./ <br /> — <br /> e <br /> DISTANCE TO NEAREST: SEPTIC TANKS SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE. PIT, . OTHER <br /> " <br /> INTENDED USE - TYPE OF WELL CONSTRUCTION SPECIFICATIONS . <br /> Industrial. ... .. e Tool Dia. .•of :Well. Excavation <br /> gestic/private Drilled Dia. of Well Casing /6 <br /> Domestic/public Driven Gauge of Casing / b <br /> Irrigation Gravel. Pack Depth .of Grout Seal 11 <br /> 4� Other Rotary Type of Grout C.D.I= <br /> h Other Other Information, �! <br /> a <br /> PUMP INSTALLATION: Coritractor nSk.,� §Sj <br /> Type of Pump H.P. <br /> f <br /> PUMP REPLACEMENT: / / 'State Work Done . � <br /> PUMP REPAIR: / / State Work Done _ <br /> ,DESTRUCTION OF WELL:. We1.1 Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with all haws and regulations .of the San Joaquin Isocal 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 /> FOR DEPARTMENT USE ONLY <br /> PHASE I : <br /> APPLICATION ACCEPTED BY DATE /,17-.;?-o <br /> t ADDITIONAL COMMENTS <br /> PHASE II -GROUT INSPECTION PHASE III FINAL INSPECTION <br /> t-- INSPECTION BY _ DATE G-7-/2,3 INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E_H 1426 4/72 1M_� <br />