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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1.601 E. Hazelton Ave..,, Stockton, Calif. <br /> Teleph6k,'�: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. _ -2-- -�-7 fi <br /> �, ]THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued <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 Joaquirn <br /> County Ordinance No. 1862 and the Rules and -Regulations of the San Joaquin Local Health District., <br /> .TOB ADDRESS/LOCATION r G 31 S JJO W L �A CENSUS TRACT ' ' <br /> Owner's Name t �N'��_ '_ r K1 I)ES _ Phone ' Ll -292-4- <br /> Address <br /> �7� ./ 4 t�Lrl=3 City <br /> _ <br /> Contractor's NameN=1 E License # Phone <br /> TYPE OF WORK (Check): NEW WELL%/ ,` DEEPEN / / RECONDITION /7 DESTRUCTION <br /> PUMP�INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT / <br /> other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY y <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE . TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation 7- <br /> - Domestic/privateDia. of Well Casing AL `f <br /> Domestic/public Driven Gauge of Casing 6 <br /> Gravel Pack Depth of Grout Seal S'O <br /> Irrigation C4 <br /> Other .Y`' ! _ Rotary Type of Grout <br /> Other Other Information <br /> C-1; . <br /> PUMP INSTALLATION: ,Contractor <br /> Type of Pump H.P'. o <br /> PUMP REPLACEMENT: / / State Work Done \ i. �T <br /> i PUMP REPAIR: / / State Work Done i <br /> ,DESTRUCTION OF WELL:: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> i - <br /> I hereby agree to cdihply with all laws and regulations of the San Joaquin Local Health District <br /> and the State of Cal fornia pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> after completion of `%y work on a new well, I will furnish the San Joaquin Local Health District a.. <br /> WELL DRILLERS REPORT'df 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 /> SIGN D TITLE <br /> Ems, (DRAW PLOT PLAN ON REVERSE SIDE) ` <br /> F FOR DEPAR MENT USE ONLY r/ <br /> PHASE T <br /> APPLICATION ACCEPTE6,�$Y _ _ _ --� � � -DATE7 <br /> ADDITIONAL COMMENTS.: <br /> PHASE II GROUT INSPECTION �_ ' �'\N PHASE III FINAL INSPECTION <br /> INSPECTION BY. ATE ��- ��-7z � �rINSPECTION"BY DATE 12 -�-��- <br /> CALL FOR A GROUT INSP.ECTI-ON"PRIOR TO GROUTING��AND FINAL INSPECTION. <br /> E H 1426 - _ ... 4/72 IM <br />