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lY SAN ZOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone:. (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 73Lv <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) .., <br /> Application is hereby trade to the San Joaquin Local Health District for a permit to construct <br /> and/or install the work-1herein described. This application is made in compliance with San Joaquin <br /> F County Ordinance No. 1852 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION i�S -� SDc� w CENSUS TRACT'-Olixe <br /> Olive 579- 3 G 9 6 <br /> Owner's Name Bernie Brink _ ._ Phone 982-1500 Ext- P36-!' <br /> Address 22 42 S&th Olive city Bj on_ Cal <br /> Contractor s Name Bg in Bros . ri in License #f Phon <br /> TYREt.OF-.W.O.RK-(Check): r;I .Etd=WELT: 3EEPEN=/ f c(3NDIT1{�N ./ ;rDEs R�icTIE3i+ f _ _ <br /> PUMP INSTALLATION / f PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Cather J / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY } <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE I TYPE OF WELL CONSTRUCTION SPECIFICATIONS Y <br /> Industrial Cable Tool Dia, of Well Excavation --201t <br /> Domestic/private _ Drilled Dia. of Well Casing 1211 <br /> Domestic/public Driven Gauge of Casing it . <br /> _ . x Irrigation X — Gravel Pack Depth of Grout Seal <br /> i Other Rotary Type' of Grout <br />¢ 1M Other Other Information <br /> .IM _ <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. ,3 Opp <br /> r PUMF REPLACEMENT: % f State Work Done ' L <br /> t PUMP REPAIR: / / State Work Done -- <br /> DESTRUCTION OF WELL: Well Diameter 1 Q 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 ofllthe well and notify them before putting the well in use. The above <br /> information is true to the be t of my knowledge and belief. No <br /> SIGNED TITLE . <br /> IM (DRAW- aOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY 5 <br /> PHASE I <br /> , APPLICATION ACCEPTED BY DATE 2/60 <br /> ( ADDITIONAL COMMENTS: 1 <br /> ( PHASE II GROUT INSPECTION P I NAL INSPECTI N <br /> INSPECTION BY 1I DATE INSPEC BY DATE - <br /> CALF. FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 lip', <br />