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-;c SAN JOAQUIN LOCAL HEALTH DISTRICT 0,4/P 6,9 <br /> FOR OFFICE USE: 1601 E. Hazel tont"A-Ve. :Stockton, Calif. <br /> Telephone: (2 0 9)".`4 6 6 r 6 7 8 1 a <br /> APPLICATION FOR WELL CONSTRUCTION.-OR PUMP PERMIT Permit No. (27 <br /> THIS P ERMI T.7EXP IRE S{J.,YEAR-FROM,-DATE -ISSUED:..--, Date Issued <br /> (Complete In-- Y4- 7'�Ttiplidate) --,! <br /> ApplicatioriUd-.-her by%made-,to t�e%,San;-,J oaquiri.1,Lo6al lldalth- Distr'ict..'f6r;a',per'diit to construct <br /> and/or install the work herein described. This'f.application­is -made Aiiin ccompli:Ance Vith..San,Joaquin <br /> County.%Ordinatce No,,,7,18 6 2 r,,and Xthd e,,Ruleg' L-atidt.-Re,gulations,-.6f,�the 7 j <br /> San, oaquin�Local,Health--District* <br /> J.1 ol t,-- '­Aj�) %1," '10 rMJ*IC: J."fi-I <br /> ' <br /> JOB ADDRESS/LOCATION 13"ly, M?e CENSUS:-TRACT <br /> Own e r s N a me e Z Alg JV. <br /> -Al x­.uQ;:Phone '1,2_3 <br /> Z <br /> )D <br /> Address7- IFo CityFse <br /> 7- 1 <br /> Contractor's Name License # Phone ' <br /> TYPE OF WORK (Check) ; NEW WELL DEEPEN '/—/ RECONDITION /_7 DESTRUCTION /-7. <br /> PUMPINSTALLATION -7 <br /> _1�64 PUMP REPAIR : PUMP REPLACEMENT <br /> Other':./ <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> -- SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL 'FIELD_ CESSPOOL/SEEPAGE PIT OTHER <br /> -A <br /> INTENDED USE I- 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 ' ' ­ --- - Gauge'of Casing <br /> Irrigation " . ---,Gravel Pack Depth of. Grout Seal <br /> Other --Rotary Type of Grout <br /> Other Other Inf6rmatioh <br /> PUMP INSTALLATION. Contractor <br /> Type of Pump H.P. <br /> AIL <br /> C11 <br /> PUMP REPLACEMENT: -State Work Done <br /> PUMP'RE�Afk­- "' ---�7– 'Sfdre,�Wor�:IboneN <br /> ,DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <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, <br /> 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 . true to the best .of .my .knowledge and belief. <br /> SIGNED TITLE <br /> 3. oye� 1 0 WA 6/ Ak <br /> (DRAWPLOff PLAN ON REVERSE -SIDE) 9, <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASF,-III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY fbC6 4&& DATE <br /> CALL FOR A GROUT INSPECTION PRIOR,TO GROUTING .AND FINAL INSPECTION. <br /> E H 1426 4/72 1M <br />