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_ I• <br /> SAN JOAQUIN LOCAL HEALTH DISTR'k. f <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. ]fir-IQ <br /> THIS PERMIT EXPIRES 1 YE-1R FROM DATE ISSUED Date Issued Z a-74 <br /> (Complete In Triplicate) <br /> Application is hereby made to thc. San Joaquin Local Health District for a 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 /> ��tST r - <br /> T#?iiCTiZ/,L-t7 x-t'CT.4 Pt: rF <br /> JOB ADDRESS/LOCATION K,' T 7, )))0 4. 4 cr)Si ciUF c ! J"k'�i� % S/lt"�2� CENSUS TRACT � <br /> Owner's Name C I:e Lt'10 i= �� u I i c) Phone tic-_ 7. 73`/ <br /> 3 <br /> City <br /> Address h 0 <br /> Contractor's Name <br /> San j n^;�"'' �� ,-� License 1 Phone 3l�'�5�7/ <br /> TYPE OF WORK (Check): NEW WELI, / / DEEPEN /_� RECONDITION /—T DESTRUCTION /_T <br /> f PUMP INSTALLATION /� PUMP REPAIR /�] PUMP REPLACEMENT /LY <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTR Q <br /> INTENDED USE TYPE OF WELL <br /> CONSTRUCTION SPECIFICATIONS �+ <br />-r" Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing < <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> x Other Rotary Type of Grout \ <br /> Oth-Rr Other Information <br />.`Iti <br />' PUMP INSTALLATIONt Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: /-W-,State Work Done gnJac e ` 7 j2 [tJ� f t L <br /> z PUMP REPAIR: / / State Work Done <br /> 'T 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. Son Joaquin Pim Co. k <br /> t (Dws,on of Son 1adgwn SU!0wr CQJ <br /> SIGNED <br /> TITLE 711 N <br /> DRAW PLOT PLAN ON REVERSE SIDE ^ <br />'1 FOR DEPARTMENT USE ONLY <br /> PHASE I DATE <br /> APPLICATION ACCEPTED BY ✓�-o <br /> ADDITIONAL COMMENTS: PHASE 11117,1 AL INSPECTION <br /> PHASE II GROUTINSPECTION INSPECTION BY DATE <br /> INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FIN.U, INSPECTION. 7/72 1M <br /> E H 1426 �. <br /> lit, <br /> j'Y <br />