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�5 7 /© ptl <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: ][/-"16(01 E. Hazelton Ave.", Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 76-l 83• W <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued A- <br /> S <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 Joaquin <br /> County Ordinance No. 1862 and. the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 2C7O,2 3 /// & R-,C ale, 650'A1,a CENSUS TRACT <br /> Owner's Name f-7Phone <br /> Address .2000/ c /y �/ .5320 City E5C/i►40N, l • <br /> Contractor's Name STev,6_E-,e V- License # /2/JPhone 537-5767 i <br /> TYPE OF WORK (Check) : NEW WELL "/ DEEPEN%/ RECONDITIONS/ / DESTRUCTIONS <br /> PUMP-INS TAIL14TION"/-PUMP REPAIR / / PUMP`REPL�ICEME /� <br /> Other <br /> DISTANCE TO DEAREST: SEPTIC TANKp SEWER LINES Wel PIT PRIVY - <br /> SEiA �SPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER ' <br /> INTENDED-,_USETYPEWOF;`WELL CONSTRUCTION SPECIFICATIONS d <br /> kms . «� <br /> Industrial. �,„. Cable-Too.1�.Dx ..Ralf Well Excavation � <br /> X Domestic/,private Drilled Dia, of Well Casing - Vii ' ' <br /> Domestic'/public D ` �cnGauge of Casing <br /> Irrigatio'n ,G avel._Pack Depth of Grout Seal �b <br /> f- Other I ' I >� Ro.tary\\ Type of Grout AE,7v7- � <br /> Ott'e`r" Type <br /> Information <br /> 101 0 AIN <br /> PUMP INSTALLAT);ON: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: /% State Work Done <br /> STRUCTION OF WELL: Well Diameter p.`� Approximate Depth <br /> Describe Material and Procedure <br /> t <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> and the Stated of; California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> after completion of my work on new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILL PORT of the w 1 land notify them before putting the well in use. The above <br /> informat on is true to the of-my knowledge and belief. <br /> SIGNED �[ TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY 4as DATE 3 <br /> ADDITIONAL COMMENTS: <br /> PHASE IOU INSPECTIO PIiA II FIN INSPECTI N <br /> INSPECTION BYJ PATE INSPECTION BY DATE <br /> CALL FOR GROUT INSPECTION PRI. T GROUTING AND FINAL INS eCTION. <br /> E H 1426 4/72 IM <br />