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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> PLICATION FOR WELLCONSTRUCTIONOR PUMP PERMIT Permit No.7 z 6 o 7 <br /> gYsrtv <br /> A THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED , Date Issued �o - 2c9• 7Z- <br /> (Complete <br /> Z(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 Rules and Regulations of the San Joaquin Local Health District, <br /> JOB ADDRESS/LOCATION LU 5 o& C2 A aF-77i40 A NTJ cad-[ /C2 R17 CENSUS TRACT .� 7 <br /> f <br /> r <br /> Owner's Name 7 M/=S O _ <br /> /�L Phone gid-vQ-3•Z-?4,4 <br /> Address 3 a G'L City R G 7 O <br /> Contractors Name 4j T(-,'/i d L S 12 GyIS � 7 6 1J L TG,q 4/F License # a,4s-e4, Phone 7�•t��os � <br /> TYPE OF WORK (Check)! NEW WELL Z DEEPEN '/-7 RECONDITION /7 DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT /- <br /> Other f% <br /> DISTANCE TO NEAREST: SEPTIC TANK /sye SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> a <br /> INTENDED USE ' TYPE OF WELL CONSTRUCTION SPECIFICATIONS V1.; <br /> Industrial X_ Cable Tool Dia. of Well Excavation H <br /> - Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout c M�IK r <br /> Other Other Information ' <br /> 5 ' <br /> PUMP INSTALLATION: Contractor IW-&- V,89AL. 1'-�&Sccp,�[ V 9� ,�y6 5-7G/ <br /> Type of Pump _s - zr�r ¢e: $ 3L-=- „}, ,,------•- H.P. S-r-lo,— <br /> PUMP REPLACEMENT: /—/ State Work Done <br /> PUMP REPAIR: /-7 State Work Done <br /> ,pESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I herebyagree 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 the best of my knowledge and belief. r <br /> SIGNED TITLE <br /> -(DnW PLOT PLAN ON REVERSE SIDE <br /> -- FOR DEPARTMENT USE ONLY -- <br /> PHASE I � � �v <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE -' INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 4/72 1M <br />