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- SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton' Ave. ,:-�S'tockton, Calif. <br /> -= - l Telephone: (209) •46.6--67$1 `(5-66 <br /> LIGATION FOR WELL CONSTRUCTION- OR, PUMP PERMIT Permit No. <br /> HIS PERMIT EXPIRES 1?YEARsFRO�i:DATE 'ISSUED Date Issued AO <br /> %2'f-675 of �i.c •' -. {ComAlete In�Triplieat'e) Oci'"7. :3j a ��5. 7�`� n <br /> Applicatioin;is�herebysmadej:to the.-San TJoaquin�_Local Health District'* for` a permit' to construct <br /> and/or install the work herein described. This::,applicarion-'is made"in;compliance -with'.San Joaquin <br /> County:.Ordinance:pNo. x18621:and{,.the•-_.Rule6,ands Regulations.-,of"the. San-Joaquin-Local Health District. <br /> �# "�'-' � �"'•-�-=fit- � � _ _ ,xsEz - . <br /> JOB ADDRESS/LOCATION � �� CENSUS-TRACT' .,57 <br /> . . - =)-?'(' �S�1 '�C 1 e _S}i a.�S} i a _.. #: _ - 1.-! i.. •- s cOwner.'.s_,Name� :�T j r_.rs.sC oi. c`.,` ' .:.. F Phone,: r 3'3 <br /> Address <br /> City <br /> Contractor's Name � License # Phone <br /> TYPE OF WORK (Check) : NEW WELL '/ DEEPEN / / RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION _X/ PUMP REPAIR/ '/ PUMP REPLACEMENT /-7 <br /> Other / / a. I <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 /> 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 C <br /> PUMP INSTALLATION: Contractor <br /> Type. of Pump �. H.P. <br /> OF <br /> PUMP REPLACEMENT: / / Stave Work Done ,� ��� , <br /> PUMP REPAIR: / / State Work Done <br /> -41 <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 cdmpletion 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 /> a <br /> SIG9ED TITLE <br /> a (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE ZOf,2-Z�_ _ <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION t <br /> INSPECTLON BY DATE INSPECTION BY DATE <br /> CALL °FOR A GROUT. INSPECTION PRIOR TO GROUTING AND .FINAL INSPECTION. r <br /> E H 1426 , .. ... :_ _. _ 4/72 IM <br />