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.r <br /> SAN JOAQUIN LOCAL I�EALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton .Ave..-; Stockton, Calif. <br /> Telephone: ,;(209) 466-;6781 <br /> PLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT- Permit No 72,5 <br /> THIS PERMIT EXPIRES• 1;,YEARjFPOM-,DATE.'ISSUED ;F_ =t,. .Date 'ls/sued 6, :7 Y. <br /> f iiyt,�+71` w '.3y C� ' ls �e?f3 ..F• :(t.'Omple,tef: nr�'r3psllCatE?� y ' v: <br /> Application is hereby made to the San Joaquin,lLocal;,Health.District :for a permit .to,construct <br /> and/or.,ins-tall ,�her,work herein,descr.ibed. ,, This application:jis made in-compliance with: San :Joaquin <br /> County Ordinance,:Na s 1862,ari-- heRRules- anclp;RAgulat3ons of..the.:San -Joaquin.,.Local,-Health District. ' <br /> JOB ADDRESS/LOCATIONrt',5,% d=: �/ ySCENSi1S,;TRACT <br /> :70 0C <br /> Owner's Name -1 TA T� G'A1 �Z ..,_ !JI V, OF lC _j&j)K_� Phone <br /> Address=- -"., �..�-. 1 - ";.__Y _ _ 5�. T-Cit <br /> y <br /> t ' <br /> Contractor's Name C ',� /(/- �� 1�� (/ /� Cd License # OZ Phone.' YtIZ-S'J J� <br /> TYPE OF WORK (Check) : • NEW WELL 'Zff DEEPEN '/_/ RECONDITION /_/ DESTRUCTION ,/_7 <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT /7 <br /> Other / <br /> DISTANCE TO NEAREST.: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD 1 CESSPOOL/SEEPAGE PIT OTHER <br /> : INTENDED USE TYPE OF WELL ' CONSTRUCTION SPECIFICATIONS <br /> _ Industrial j Cable ToolA. Dia. of Well Excavation <br /> Domestic/private Drilled y w Dia. of Well Casing A <br /> t _ Domestic/public r, - Driven Gauge of" Casing <br /> frigation Gravel Pack Depth of- Grout Seal z _-a' . <br /> Other teary 71 Type of Grout -- - -L6- FIV 7 n <br /> -_-- Other Other Information ] <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMA' REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: State Work Done <br /> ,DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe :Material and Procedure <br /> ! __ <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) T <br /> . . FOR DEPARTMENT USE-ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS i. <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY <br /> - - - ; DATE `7- -- <br /> 6AI:L-POR—A-GSR UT-'INSPECTION"'PRIOR TO 'GROUTING AND FINAL INSPECTION. - <br /> E H 1426 4/72 IM0 <br />