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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6781 j <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> I THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 3 <br /> (Complete In Triplicate) <br /> Application 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 Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 31:2.49 E... COMBS ROAD CENSUS TRACT <br /> Owner's Nage OMER. IHRIG Phone 838-2870 <br /> Address SAME City. <br /> Contractor's Name T .D. SUTTON' AIS SON <br /> License # 279010 Phone 838-4M7 <br /> TYPE OF WORK (Check): NEW WELL /% JDEEPEN /- `RECONDITION /�7 DESTRUCTION <br /> PUMP INSTALLATION J / PUMP REPAIR /C/ PUMP REPLACEMENT /7 <br /> Other / / -- <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVYAi <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 /> Domestic/private Drilled, �,� {. .Dia.,, of Well Casing <br /> Domestic/public Driven� � Casing <br /> - of Gauge <br /> • g <br /> Irrigation"`""`-`= Gravel•, Pack ' % Depth of Grout Seal <br /> Other ��sr r ' Rotary 4 Typerof Grout ' <br /> A <br /> r 1 Other _ Other{, Informations <br /> F t <br /> _y f 4 t <br /> '`PUMP INSTALLATION: Contractor„ , <br /> Type-of-Pump H.P. <br /> PUMP REPLACEMENT: /�/ State Work Done <br /> '/ffT—State;-Work Done REPO. ;Pe—JET-PUMP-41_ _ <br /> PUMP'REPAIRo :_ -.-�.- VE 1' HREPAIR AND REFACE <br /> ESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe MAterial and Procedure 'r <br /> I hereby agree to comply ,rUith -all °laws-a - 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 rue to th best of-'my knowledge and belief. <br /> SIGNED TITLE PARTNEIR <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY ' <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT IN ECTION WSF,,0rIyjM INSPECTION <br /> INSPECTION BY DATE INSP ON BY TE <br /> K CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />