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SAN JOAQUIN�LOUL gALTH DISTRICT <br /> FOR OI"FICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> ETelephones (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR P R I,T Permit No. �-66110 <br /> THIS PERMIT EXPIRES Z YEAR FROM 7?ATE mae Issued ,CJ //-7l <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 incompliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> o ao <br /> JOB ADDRESS/LOCATION ..t 7�`,,�,t �y�, jf ,�� C{ s TRACT 7 <br /> 11 V <br /> Owner's Name �.t. � ®�c.ti�,J Phone - <br /> Ad dre s s <br /> hone .Address f City ' c2e,�A <br /> Contractor's Name Licensed f' cLs Phone '' o.#( <br /> TYPE OF WORK (Check) :..._NEW ,WELL ,/ '�DEEPEN:/ _/.PRECONDITION -/_/_ .DESTRUCTION <br /> PUMP INSTALLATION,0 7 PUMP REPAIR/ / PUMP REPLACEMENT /_7 <br /> Other — <br /> i 4" <br /> k DISTANCE TO NEAREST: SEPTIC TALK �!_ SEWER LINES _ PIT PRIVY <br /> SEWAGE DISPOSAL-FIELD -- - -- -CESSPOOL-/SEEPAGE PIT OTHER ; <br /> i <br /> INTENDED-USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS_ <br /> Industrial _ Cable Tool Dia, of �We1l..Excavation /6 <br /> Domestic/private Drilled Dia, of Well Casing <br /> i - Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal 'd <br /> Other Rotary Type of Grout <br /> Other Other Information - - - 0 <br /> d <br /> ?. <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. ' <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: fi / / State Work-Done <br /> r <br /> .DESTRUCTION OF-WELI;:- `""We--11 -Diaiueter' <br /> t 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 new well, I will furnish the San Joaquin Local Health District a <br /> l WELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> information is true to t e best of my knowledge and belief. <br /> i <br /> SIGNED A TITLE <br />+ (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE/e) 7 7-- <br /> ADDITIONAL COMMENTS: <br /> PHAS GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE/d - INSPECTION BY /,fo DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 E .;_ 4/72 1M <br />