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& <br /> SAN JOAQUIN LOCAL' NEALTH DISTRICT <br /> FOR OFFICE USE: /APPLICATION <br /> 601 E. Hazelton Ave. ,; Stockton, Calif. <br /> Telephone: (209) 466-6781 i <br /> FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 72.21 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE LSSUED Date Issued 7- z 7. -7z- <br /> (Complete <br /> . 7z(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 Joaquin <br /> County Ordinance No.- 1862 and the u1 and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION - - ecrx f tS-eep CENSUS TRACT r� <br /> � f <br /> Owner's Name yam, �.0 cr „ .� Phone 46 i f G 4�� <br /> Address 3� � �" �, /A��.l�r-r.�f City ; <br /> Contractor's Name611�;, _-_- _ License ���$�13',p+ / Phone-74,5-4 <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN '/�/ RECONDITION /"7 DESTRUCTION /_7 <br /> PUMP INSTALLATION/ / PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other <br /> r <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 yC Cable Tool Dia. of Well Excavation <br /> y_ Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal 5--p` ,.�. '. <br /> Other Rotary Type of Grout G SW -Al <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> -761 <br /> Type of Pump H.P. .2'-/70 <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: '" / / State Work Done <br /> ,DESTRUCTION 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 <br /> after completion of my work on a neva 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 /> 41 <br /> SIGNED _ e.- <br /> _ TITLE <br /> (DRAW- PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION * PHASE III/FINAL INSPECTION <br /> INSPECTION BY f ol. DATE F ? • ? .2 - INSPECTION BY DATE <br /> GALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 4/72 1M <br />