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yam- <br /> SAN JOAQUIN LOCM, HEALTH DISTRICT <br /> FOR GFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> { Telephone: (209) 466=6781 <br /> PLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISS[JED Date Issued <br /> (Complete In Triplitate) <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 `x M=0f;gPgF Ea <br /> 1ji e <br /> .._ s , Q ',Deres CENSUS TRACT <br /> exid Thornton Rds.' <br /> Owner's :Name Kn.s>� o.s& Phone 368-6623 <br /> Address _ _ X3245._ I_ Thornton,Road, � ` CityLodi <br /> Contractor's Name S u SLQaqu--alr�� CO==,^J13r, Z.Qox ,.._„ License # 271800 Phone 369-8 71. <br /> { <br /> TYPE OF WORK (Check) ; NEW WELL -/j/ DEEPEN 'fv/ RECONDITION /_� DESTRUCTION /_7 1 <br /> PUMP INSTALLATION/ / PUMP REPAIR / / PUMP REPLACEMENT /_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 I,t., . <br /> Industriale� <br /> y, Cable Tool Dia. of Well Excavation 8 1 <br /> - Domestic/private Drilled Dia. of Well Casing 8t' <br /> Domestic/public Driven T Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout Y'►:5 <br /> Other - Other Information <br /> PUMP INSTALLATION: Contractor j <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 /> Describe Material and Procedure <br /> i <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 cons-traction. 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 kno edge and belief. <br /> SIGNED ` a ` TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY 1 <br /> PHASE I { i <br /> APPLICATION ACCEPTED BYDATE 7 z- <br /> ADDITIONAL COMMENTS: <br /> PHAS II GROUT INSPECTION PHAS III/FINAL INSPECTION <br /> INSPECTION BYE ' 'DATE 3-7z- INSPECTION BY DAT <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING' AND FINAL INSPECTION. <br /> E H 1426 ' 4/72 1M <br />