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cSAN JOA <br /> FOR OFFICE USE: QUIN LOCAL HEALTH DISTRICT <br /> 1601 E. Hazelton Ave, , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 6 <br /> (Complete <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 Regulations of the San Joaquin Local Health District.— <br /> JOB ADDRESS/LOCATION Soj3thWeSt Corn <br /> 0Baker Road§ENSUS TRACT <br /> Owner's Name __.Ian R <br /> Phone <br /> Address ___11090 F_ ker Ao ,d <br /> City StocktonContractor's Name _ Linden Seri tae pumps <br /> License # APpliedPhone 887-3698 <br /> TYPE OF WORK (Check): NEW WELL / / DEEPEN /-7 RECONDITION /-7 DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR / PUMP REPLACEMENT J)C7 <br /> Other <br /> 'DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> PIT PRIVY <br /> Unknown SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER \ <br /> (Replaced old <br /> pump) <br /> � <br /> INTENDED USE TY PE OF WELL CONSTRUCTION SPECIFICATIONS -41%Industrial __ Cable Tool Dia, of Well Excavation Q <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 r,i nd n 4orvi P pr�,,,nfi <br /> Type of Pump Line SIRAft '1'nrb4rie H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: !' / State Work Done <br />,DESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure Approximate Depth <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 Qc4—s-J-z A r,%-,+,, k,, 0 .�� <br /> TITLE a t <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: DAT <br /> PHASE II GROUT INSPECTION p <br /> INSPECTION BY DATE N INSPECTION <br /> INSPECTION BY DATE <br /> CALL FOR A GROUT <br /> E H 1426 INSPECTION PRIOR TO GROUTING AND FINAL INS <br /> 7/72 1M <br />