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e. <br /> + SAN JOA()iIIN LOCAL LTH DISTRICT T <br /> FOR OF ICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.,;'�25 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued/D—//rat <br /> (Complete In Triplicate) <br /> Application is hereby made tok 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 6-A (0 N0R A P A In CENSUS TRACT <br /> Owners Name lei I N 5 431-Al i. -7 -- Phone �7 x- g 2- Lf 4/ <br /> Address -7 rG ,[� � 1/ - -- - -- -- City S T! N <br /> Contractor's Name 3Z_4,�/f ��� .fM4R -� ` License #,,7 ,� is~ Phoneq??i85 g <br /> TYPE OF WORK (Check): NEW WELL §07 DEEPEN / / RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK 7 SEWER LINES t. PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER (JI <br /> t CA , <br /> INTENDER USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial t Cable Tool Dia. of Well Excavation -/0 6 <br /> )4 Domestic/private T- Drilled Dia. of Well Casing <br /> Domestic/public Driven � M Gauge of Casing ��- <br /> Irrigation 4 Gravel Pack Depth of Grout Seal �c4 <br /> Other i1 1( Rotary t Type of Grout <br /> I Other w '" FOther Information <br /> A <br /> PUMP INSTALLATION: Contractor <br /> 4 <br /> Type of..Pump. H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> 1� <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 new well, I will furnish the San Joaquin Local Health District a <br />, WELL DRILLERS REPORT of the we11 and notify them before putting the well in use. The above <br /> information is true to the best of my knowledge and belief. 1 <br /> SIGNEDe, ^mss TITLE S ; <br /> -'(DRAWPtOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I .II <br /> E APPLICATION ACCEPTED BY E/ /J� 9� DATE <br /> ADDITIONAL COMMENTS: t <br /> PHASE II GROUT INSPECTION PHASE I I/FINAL INSPECTION 5 } <br /> INSPECTION BY . DATE INSPECTION BY dDA;CE -2 <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. C 7 <br /> E H 1426 7/72 1M / <br />