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SAN JOAQUIN LOCAL HlL,ALTH DISTRICT <br /> r <br /> FOR OFFICE USE: 1601 E. Hazelton Ave-, Stockton, Calif. <br /> Telephone: (209) 466-6751 <br /> P ICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7Z_ q L 7 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 5 <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 with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION' , p Li IV aJ, CENSUS TRACT <br /> Owner's Name <br /> ,�__�,.rP®W E- L Phone 1,19- 7.t�f J^ p <br /> Address SA A4 City �S C A kis J✓ <br /> Gentrat r4s Name T, License # Phone R',;?S -.2207 <br /> TYPE OF WORK (Check) : NEW WELL/�/ DEEPEN /_/ RECONDITION /-7 DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT <br /> Other L/ <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 W <br /> Industrial Cable Tool Dia. of Well Excavation to <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 <br /> PUMP INSTALLATION: Contractor - , S,,,•r Tc,,q 4- o rJ <br /> Type of Pump S u b, H.P. r <br /> PUMP REPLACEMENT: /State Work Done Pui/ jA,r- me?. 6. Th/S `no/ l .e S:s b. <br /> PUMP REPAIR: /—/ State Work Done <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 DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY �� J u� ' DATE S <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION s, <br /> INSPECTION BY DATE INSPECTION BY -��©, DATE _-5 <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 4/72 1M <br />