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SAN; JOAQUIN LOCAL HEALTH DISTRICT '.. <br /> FOR OFFICE USE: 1601 E. Haielton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR DELL CONSTRUCTION OR PUS PERMIT Permit No. <br /> a_ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date ,Issuied,/r/- <br /> ^ (Complete In Triplicate),_ <br /> Application is hereby made. to the 'San Joaquin Local Health District fora 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 /> - <br /> .JOB ADDRESS/LOCATION - _�/� S 13C�!�f' `7 �_ -_ - - - CENSUS TRACT : 5 <br /> Owner's Name S G k1 IV Ll.l~1' IF Phone <br /> 1?AIV I') Y A 4 t?e1r7,S01V <br /> Address P11 :13G City t 1 Al T'H_Vii+-� <br /> Contractor's Name c ) I AII! *IL I leat) ip. G 1d, License # %^ C G.z Phone;ti�z z- <br /> TYPE OF WORK (Check) : NEW WELL L' DEEPEN /_/ RECONDITION /_7 DESTRUCTION /7 <br /> g PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /? <br /> Other /_7 <br /> DISTANCE TO NEAREST: SEPTIC TANK 160 SEWER LINES PIT PRIVY <br /> } SEWAGE DISPO Al, PIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation 2 - - <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing �_�,Sra <br /> I . X Irrigation X -Gravel Pack Depth of Grout Seal _ <br /> Other _ Rotary Type _of Grout- t' <br /> IN Other Other Information ~ <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump l H;P. , � <br /> PUMP REPLACEMENT.- _ - /- -State�Work Done <br /> PUMP REPAM - / / State Work Done <br /> ,RESTRUCTION 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 /> y�rrss <br /> �� <br /> SIGNED TITLE 61 7 ,' _- <br /> :IM (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I' ` <br /> APPLICATION ACCEPTED BY <br /> f ADDITiONAL COMMENTS: ' C P 6AI Ail c_ RT ►.!' <br /> PHASE II GROUT INSPECTIONc ,P E -INSPECTION <br /> [[ INSPECTION BY (R ()� I'� DATE ' ` 1' ': k INSPECTION BYE..'. DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E x 1426 <br /> 7/72 IM <br />