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- --�- SAN JOAQUIN LOCAL :tEALTH DISTRICT <br /> a FOR OFFICE USE: 1601 E. Haie'l-ton Ave.`; 'Stockton, Calif. <br /> Telephone: . (209) 466=6781 <br /> P �ATION FOR WELL CONSTRUCTION OR- PUMP PERMIT Permit No. 7 7-- 3 S <br /> THIS PERMIT .EXPIRES 1 'YEAR `FROM DATE' ISSUED,- Date Issued 9_ `{ -7;?_1 <br /> (Complete In Triplicate) ' <br /> Application ,is hereby _madaito 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 Joaquin <br /> County Ordinance .No. -1862 and-,the Rules'and Regulations' of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 5`q fj� w C zj R , ' z 7Z Ta m 7- CENSUS TRACT <br /> r Owner's Name xrt Phone 46 V wl 6 3.. .' <br /> Address 2' S AIM 1(/ City _ $' <br /> Contractor's Name GZ�j j j �y License # __45—o_9_ Phone <br /> 1-TYPE OF WORK (Check) : NEW WELL DEEPEN '/_% RECONDITION /� DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR ' PUMP REPLACEMENT 1_7 <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 CONSTRUCTION SPECIFICATIONS <br /> Industrial ^ Cable Tool Dia, of Well Excavation <br /> _ X Domestic/private Drilled Dia. of Well Casing _ all <br /> Domestic/public Driven _ Gauge.of Casing !2 <br /> Irrigation Gravel Pack Depth of Grout Seal 92 <br /> Other Rotary Type of Grout � �� <br /> Other Other Information ' <br /> ( ' PUMP INSTALLATION: Contractor u :165-76 <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 /> f,. Describe Material and Procedure <br /> s <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 /> SIGNEpl �t .r ' nom. c TITLE <br /> -(DRAW-TtOT AN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> I PHASE I <br /> APPLICATION ACCEPTED BY DATE 2 Z_ <br /> ADDITIONAL COMMENTS: <br /> P SE II GROUT INSPECTION PHASE-III/FINAL INSPECTION <br /> INSPECTION BY DATE — — INSPECTION BY DATE <br /> t CALL FOR OUT INSPECTION PRIOR TO GROUTING AND FINAL INSFECTIO . W@� <br /> E H 1426 4/72 1M <br />