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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR4�OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. to <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.7 _/6 eu <br /> THIS PERMIT EXPIRES .1 YEAR FROM T ISSUER Date Issue7S d <br /> a-73 <br /> (Complete in Triplicate) <br /> Application is hereby made to the 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 Joaquins <br /> County Ordinance No. 1862 and the Rules and Regulations of- the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION <br /> CENSUS TRACT Sq '7 <br /> Owner's Name M 6U c L L Phone 41v y ; <br /> Address <br /> R—' 5­ E &� c N . . city _.S_7'/'Al,..,, <br /> Contractor's Name A Z o S S License #1 t, Phone one 74s'ics <br /> I <br />--TYPE-OF WORK (Check) : ]EW­WELL-ff--DEEP EN'7_%—"-RECONDITION_-/ l �— <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other / J — <br /> DISTANCE TO NEAREST: SEPTIC TANKS ;SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL SEEPAGE PIT IT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial �X Cable Tool Dia. of Well Excavation / f� <br /> X _ Domestic/private I Drilled Dia, of Well Casing <br /> Domestic/public Driven Gau e�of Casing <br /> .+. <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> --- -- Other 1 Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor - ,� I I <br /> E <br /> Type of Puhp X c� - .,. H.P. <br /> 2— <br /> PIM <br /> PUMP REPLACEMENT: J / State Work Done <br /> S <br /> R <br /> r <br /> PUMP REPAIR: / J 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 k <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 s <br /> TITLE <br /> {DRAWPL LAN ON REVERSE SIDE <br /> PHASE I <br /> FOR DEPARTMENT,USE ONLY <br /> - - . - <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: I <br /> PHASE II GROUT INSPECTION PHASE I I FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE Z - 2- Z3 <br /> CALL FOR A GROUT INSPECTION#PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 <br /> �� / 7/72 1M <br />