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= i <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> R. ,OFFICE tSEl: i 16€ 1 E. Vazeltan Ave. , Stockton, Calif. <br /> Telephone: (209) ..466-6781. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> Permit No. d GL <br /> THIS PERMIT EXPIRES I YEAR FROM DATE: ISSUED Date/Issued I S 7Z <br /> ' (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct 1; <br /> and/or install, the work herein described. This application is made in compliance with San Joaquin p` <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> i <br /> Owner's Name p �/ Avv, ei`*,J646 Phone ' <br /> Address C34 .� �fc�- � 7��r /C ram City <br /> Contractor's Name Y��. � , �. G License k2b&7V96 Phone <br />,_TYPE_.OF.WORK,(Check);�N.EW-WELLe��DEE£ri�iQ__ �/�G(3NDITiON� s �" '� ' _- <br /> . �_ /�---DES�RUCTiON /�Y <br /> PUMP INSTALLATION / / PUMP REPAIR '/—/ PUMP REPLACEMENT /_ <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL <br /> _ CONSTRUCTION SPECIFIC <br /> ATI S , <br /> Industrial Cable Tool Dia, of Well Excavation ' <br /> - Domestic/privat Drilled Dia, of Well Casing <br /> - _ Domest:L lic Driven Gauge of Casing <br /> irrigation Gravel Pack Depth of Grout Seal <br /> IT7 0- <br /> Other Rotary Type of Grout C1 <br /> Other Other Information <br /> PUMP INSTALLATION: <br /> Contractor <br /> Type of Pump7 H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> .DESTRUCTION OF WELL: , .--Well.r.Diameter Approximate Depth <br /> Describe Material and Procedure rT <br /> f. <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District I <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 REPO;f�o <br /> well and notify them before putting the well in use. The above <br /> information is t the bes knowle ge and belief. <br /> SIGNED /w/� 1KK <br /> �-C� TITLE . <br /> fAIR PLOT 'PLAN ON REVERSE SIDE) <br /> FOR EPARTMENT USE ONLY <br /> PHASE I rt <br /> APPLICATION ACCEPTED BYCL6R&4 DATE ' Z- <br /> I <br /> ADDITIONAL COMMENTS:_ r <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTIO <br /> INSPECTION BY ;' �u _ DATE ZL-1 7-Z INSPECTION BY DATE <br /> 11-�CALL FOR A GR9'UT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTIO . I <br /> E 'H '1426 4/72 IM <br />