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.. A; � SAN JOAQUIN LOCk HEALTH DISTRTCT <br /> FOR OFFICE USE: 1601 E. Hazelton Abe. , Stockton, Calif. � <br /> Telephone: (20`9) 466--6781 / <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES I YEAR FROMI DATE ISSUED ; Date Issued <br /> (Complete In Triplicate) 99r66 <br /> hereby Made to the San Joaquin Local Health District for a permit to nstruct , <br /> Application is y <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. f <br /> �I <br /> JOB ADDRESS/LOCATIONCorner o Graham raham CENSUS TRACT S�. <br /> Owner's Name JackPhone <br /> _ <br /> Address. City <br /> Ad / - - �^-� <br /> Contractor's Name A,Je" ess6 License # 7 4 Phone _ <br /> iQ. <br /> TYPE FOF WORK (Check) : NEW WELL '/-* DEEPEN '/ / RECONDITION / / DESTRUCTION /7 � <br /> i PUMP INSTALLATION /3V�PVM� REPAIR / / PUMP PREPLACEMENT /—T <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ri PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE 'TYPE OF WELL CONSTRUCTION SPECIFICATIONS W <br /> Industrial Cable Tool Dia. of Well Excavationp Q <br /> X Domestic/private: Drilled Dia. of Well Casing 6 {n1 <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation ; . — Gravel Pack Depth of Grout Seal 501 <br /> Other Rotary Type of Grout Cement <br /> Other Other Information ' <br /> 1J t <br /> f <br /> PUMP- INSTALLATION: Contractor A.J.Kesse3. <br /> Type of Pump SU-bmersibl,e H.P. � W P — <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> L. Well Diameter—_.- .. . None. � _-Appr.oximate._Depth <br /> ESTRUCTION OF WEL <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 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 t e best of my knowledge and belief. <br /> SIGNED TITLE �1 <br /> j� (DRAW PLOT PLAN ON REVERSE SIDE) <br /> V "Y FOR DEPARTMENT USE ONLY <br /> PHASE I DATE a " <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: Ip, <br /> PHASE IIJGROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE Z-A,3-1 INSPECTION BY ,%}'- ,_ DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 4/72 .1M <br />