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SAN JOAQUIN LOCAL HEALT'r] ,DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave.; .Stockton, Calif. <br /> Telephone: .(209')':466'_6781 <br /> I VPLICATION FOR WELL ''CONSTRUCTION OR PUMP PERMIT Permit No. Z&-3 !5 / <br /> THIS PERMIT EXPIRES- 1 YEAR`FROM-DATE-ISSUED- Dare Issued 7'Z/ �— <br /> (Complete in-Triplicate) c. j <br /> Application, isc:herebysmade,to the„San Joaquin. Local Health District'•for a: permit- to construct <br /> and/or install the work herein described.' This application i's:made in compliance with San Joaquin <br /> County Ordinance, No..J862 andxthe: Rules'.and Regulations'of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION <br /> `j /j- „L CENSUS TRACT ” <br /> Owner;s «Name t =` w' �l ,S C% 5 Phone . . r <br /> Address City <br /> Contractor's Name j�, Li'cense' 74G0;_Phone <br /> ,WELL ._DEEP N-_—/ RCCNDTYPE OF_:WORK:(Check)--:—NEW �IT-�I--0�N/-7- -D- EST.,.R.UCT.ION —7_� a..... <br /> . <br /> PUMP INSTALLATION / PUMP.REPAIR REPAIR / I PUMP REPLACEMENT 1_7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC. TANK SEWER LINES PIT PRIVY <br /> --'--,SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER ' <br /> f <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation _ <br /> Domestic/private Drilled ( Dia. of Well Casing - - / t <br /> Domestic/public Driven Cauge of Casing 02 <br /> --- <br /> % Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout J� <br /> -- <br /> Other,` ' Other Information <br /> ' f I <br /> ,_,. .. <br /> II PUMP INSTALLATION: Contractor <br /> Type of Pump 'i H.P. <br /> li PUMP REPLACEMENT: / / State Work Done <br /> T F <br /> 1 a <br /> PUMP REPAIR: / State Work Done -- j <br />'-;DESTRUCTION-OF WELL: -Well-Diame ter= -'P'--- Approx±mar -Depth <br /> Describe Material and Procedure <br /> f <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 p g to or regulating well construction. within FIFTEEN-DAYS <br /> after completion of my work on a new well, I will furnishjthe 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 belidl. <br /> - F <br /> SIGNED I�Ql_ —�f s-- TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> li PHASE I <br /> APPLICATION ACCEPTED BY <2� <br /> DATE e- — <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHA EII/ INAL INSPE T ON <br /> INSPECTION BY DATE ._ INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. _ - <br /> E H 1426 - 4/72 1M R <br />