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SAN JOAQUIN LOCAL HEALTH DISTRICT 1#I <br /> FOR 0 CE USE: 160.1 E. Hazelton Ave. , Stockton:, Calif. <br /> Telephone: (209) 466-6781 <br /> PLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 72_ '? $ + <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -7Z <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 Regulation¢s .of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION ` 2382 S- _��S'C,� 14� ,6�2% —� CENSUS TRACT .`_ <br /> Owner's Name _ S zq C._t a 4,4,9 LL_;:_ . -- Phone F& Y c;7365? <br /> Address City <br /> Contractor's Name _ � Seg,-) �/ License U Phone g38:1267 . <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN/_/ RECONDITION /_/ DESTRUCTION /_7 <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 PITS r•%OTHER __ <br /> INTENDED USE TYPE OF WELL CONSTRUCTION. SPECIFICATIONS <br /> Industrial Cable Too!' r 'Dia. of Well Excavation t/V <br /> Domestic/private Drilled Dia. of Well Casing 4/d <br /> Domestic/public Driven Gauge of- Casing QQ " <br /> Irrigation Gravel Pack Depth -of.Grout Seal <br /> OtherRotary Type of Grout <br /> Other Other%lnformation <br /> 1 . <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: j_/ State Work Done r <br /> PUMP REPAIR: /State Work Done -------- - - ---- f, 1 -- --r".'—d <br /> -C2 LEI <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 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 /> SIGNED TITLE, <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPMENT USE ONLY ? <br /> PHASE I <br /> APPLICATION ACCEPT Y DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BYDATE - INSPECTION BY DATE _Z--Z0_-�7/ - <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E 'H' 1426 4/72 IM <br /> G <br />