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SAKI JOAQUIN LOCAL UEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton .Ave:, Stockton, Calif. <br /> Telephone. (209) 466-6781 <br /> AP KATION FOR WELL CONSTRUCTION OR PUMP PERMITPermit No. 1zIU3 <br /> THIS PERMIT. EXk'IRES 1' YEAR FRO�irD7.TE ISSUED Date Issued <br /> " (Complete In Triplicate) .. <br /> Applicati=r:-is_her by de 1 . <br /> -to :_t_he*San Joaquin Local Health District for a' permit to- construct <br /> and/or install the work herein described. This applicatlon-is made incompliance with San Joaquin <br /> r County Ordinance--No., 1$62 and' the Rules and -Regula.tions•'of,the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION / / / CENSUS TRACTS 9 7 <br /> I Owner,'s' Name' . y 01as r.; Phone r <br /> h; <br /> ,:Address / .. . iCit , <br /> y <br /> r Contractor's Name p , a License #/ Phone 4y, fE" <br /> t .4 <br /> �. <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN /% RECONDITION /- DESTRUCTION /- <br /> PUMP INSTALLATION/ / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PTT 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 /> �C Domestic/private Drilled i Dia. of Well Casing W <br /> 7 Domestic/public _ Driven Gauge' of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout ` <br /> f. Other Other Information ' 09 <br /> PUMP INSTALLATION: Contractor F .a <br /> 44 Type of Pump H.P. <br /> f ; <br /> PUMP REPLACEMENT: State Work .Done _ <br /> PUMP REPAIR:- //—S.ta,te-Wo.rkYDone . <br /> ,DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> bescribe 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 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 an b 'ef, i <br /> SIGNED LE i <br /> 4 <br /> W PLO PAN ON REVS E SIDE) <br /> PHASE I <br /> FOR PARTMENT USE ONLY <br /> ' <br /> APPLICATION ACCEPTED BY `. DATE 5�— /-5 <br /> ADDITIONAL COMIMNTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION T <br /> INSPECTION BY -- DATE INSPECTION BY - ,-4 DATE -/f' -/ <br /> CALL FOR A ,GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. � f <br /> E H 1426 .e <br /> 4/72 1M <br /> mow— <br />