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SAN'JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton'Ave. .,"Stockton, Calif. <br /> Telephone: (20 ) '44,6781 <br /> PLICATION FOR WELL CONSTRUCTION'.OR PUMP PERMIT Permit No. <br /> _n . <br /> THIS PERKlIT :EXPIRES..I YEAR"FR03 DATE ISSUED Date`Issued <br /> '(Complete--In" ,.Triplicate) "> . <br />' Application�isahereby made-.to 'the,< San.,Joaquin Local Health District.'for -a permit to construct <br /> and/or install the work herein described. This._applicationyis 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 11F t10 CENSUS-TRACT . <br /> e <br /> Owner's Name "t :!y!®Y�.✓f SSA!//�/.�' -�. �, - `.. --- ��- °= Phone ' <br /> Address /S S W 4a k1 m_ - - ____ City - <br /> Contractor's Name . ±0kJ ,� License # /y+ hone <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN %/ RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION/ / PUMP REPAIR �/ PUMP REPLACEMENT /? <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 <br /> F .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 Information ' O <br /> PUMP INSTALLATION: Contractor ZF2%J- . <br /> 42 <br /> Type of Pump X' H.P. ,G a h$3-- <br /> PUMP REPLACEMENT: / / State Work Done <br /> i <br /> PUMP REPAIR: 13U State Work Done Y � ► �t. ,�__ __- r.9�a ...�.� _ , <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 th well use The above <br /> information is true to the best of my knowledge and belief, <br /> SIGNED 4z _. je ­26 TITLE a_ ` <br /> (DRAW PLOT PLAN ON REVERSE SI <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY �/y-� V `� DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS III/FINAL INSPECTIO <br /> ! INSPECTION BY DATE INSPECTION BY 1A,I r7 DATE f / <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTI . i ' <br /> E H 1426 4/72 IM <br />