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SAN JOAQUIN LOCAL HEALTH DISTRICT C <br /> ".OFFICE USE: 1601 E. Hazelton`Ave:. •Stockton, Calif. <br /> Telephone:'. (209) 466-6781 0079-j#/ <br /> APPLICATION FOR-WELLCONSTRUCTION.OR PUMP PERMIT Permit / <br /> A 'n ��� THIS PERMIT EXPIRES 11YEARIFROM DATE ISSUED Date Issued 71 <br /> r t -(Complete 'Ill. Ttiplicate) <br /> p lAtio isaherebyimadelto the)San 5Joaquin' 'Local Health District for a permit to construct <br /> and/or install the work herein described. Thiir application. is made in compliance with San Joaqt <br /> County.,,Ordinance. No:;1862nand}the'.Rules'':and'•Re'gulations- of the San Joaquin Local- Health District <br /> so .:1rrl11.'<- 1' .'u r/yJJ: <br /> JOB ADDRESS/LOCATION 30�3 6 C A�?�7Z VCa(••, X'Ao wI�/4�1) CENSUS TRACT <br /> •. f „t Tt. .4 Yl3g03c'� ..11 zJ`��3m ! r J�' .a . <br /> Owner's;Name �j , 'IVHi�./i�4thf '� �0 /7�a7. ^' 'Fet.rr, n r , Phone S5?9 13'7 7 <br /> Address f� / c [� .t U P ilU E �g s3 — city Al .OE57Z5 <br /> Contractor's Name License .#a30/jPhoneS -Oe C <br /> ,.TYPE-OF-WORK (.Check) :_ NEW. WELL 'RT� DEEPEN /7 RECONDITION /7 DESTRUCTION /7 :+ <br /> " PUMP INSTALLATION ' f PUMP REPAIR/ / PUMP REPLACEMENT. /7 --` - <br /> 1 Other / / 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/prida-teDrilled Dia. of Well Casing ' <br /> Domestic/public ' Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other 1;;.-% Rotary Type of Grout h�)F <br /> Other Other Information " <br /> PUMP INSTALLATIONt X Contractor tv- <br /> 7` Type of Pump ' ! H.P <br /> _ �TuesrtiE) <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: ti,. 1 „ . '/ / State Work Done <br /> DESTRUCTION OF. WELL:. Well Diameter � . Yom, >,—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 m work on a new, well, I will furnish the San Joaquin Local Health District <br /> WELL DRILLERS T f t e well ay them before putting the well in use. The above <br /> information i t e o t of my 'kn6wledge and belief, x <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SID <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY t' �: DATE ,2G <br /> ADDITIONAL COMMENTS,: <br /> PHASE II GROUT INSPECTION PHA F AL INSPECTION <br /> INSPECTION BY . DATE INSPECTIONrBX Z DATE <br /> CALL FOR A GROUT.INSPECTION PRIOR.TO GROUTING ANDjFINAL. INSP TION. , <br /> E H­142_6 ; 'de 4/72 1M <br />