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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: fir., . 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 V3 <br /> APPLICATION ..FOR-WELL.CONSTRUCTION OR PUMP PERMIT Permit No. <br /> lease `f� Tom. l� a --THIS PERMIT IRES--I-Y-EA DATE 'ISSUED ' Date Issued �7 to <br /> (Complete In Triplicatol <br /> Application is hereby made to the Sa y -Hea3rt3�District for a permit to construct <br /> and/ox install the work herein described. This application is made in 'compl.iance with San Joaquin <br /> County Ordi anceN 1862 ,and the Rules and Regulations. fithe San Joaquin Local. Health District. <br /> 4#;1, �t d p - e!fZL rrt1. ei jd�y� —� !� � <br /> �/ � I <br /> CENSUS TRACT <br /> JOB ADDRESS/LOCATION '� �+� �� �'f�i '� <br /> �i <br /> Owner's Namej %p� Se,11qe��. fc� ./o/��� � J iP S/Z . Phone ' <br /> ---: L�n�' � mac.�� w, - � STS�✓:�..� c 1_17 <br /> Address ��6 L�•r9. City <br /> Contractor's Name Sri-' License V Phoneme - ✓�? <br /> Ty-PE-OF-VOMC-(_Ch_ec_k): 'NEW WEL f-7"DEEPEN.`./-7-_RECONDITION%7TDESTRUCTION- /7­�- <br /> PUMP INSTALLATION / / PUMP REPAIR '/ / PUMP REPLACEMENT <br /> Other /% <br /> DISTANCE'_TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF'WELL CONSTRUCTION SPECIFICATIONS € <br /> Industrial [,� Cable Tool Dia. of Well Excavation I <br /> Domestic/private Drilled Dia. of Well Casing �Z-5 <br /> Domestic/public Driven Gauge of Casing i <br /> 1,.-. Irrigation Gravel Pack Depth of Grout Seal <br /> I Other Rotary Type of Grout <br /> ¢ Other Other Information ' e7 4L— <br /> I <br /> f PUMP INSTALLATION: Contractor <br /> Type of Pump _ .6 j`•2 G 9�S ��07-vz V 41-4:�_L2-ftl -- H.P. <br /> PUMP REPLACEMENT: / / State Work Done � ' L <br /> f <br /> PUMP 'EA�1 • / State Work Done - -� <br /> ESTRUCTION OF WELL: Well Diameter - �" R "` "�`� `"� Appfoic mate I j-­ <br /> ribe Material `Pro' re <br /> D i wele e.nY0fveel <br /> o-comply with s 1 la and regulations of the San Joaquin Local Health District, <br /> and the State of California pertaining to or regulating well construction. Within F'IFTEE. 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. _ <br /> SIGNED '/'� _ TITLE ` <br /> DRAW PLOT PLAN ON-REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I O <br /> APPLICATION ACCEPTED BY DATE ' <br /> ADDITIONAL COMMENTS: <br /> PHASF,,II GROUT INSPECTION PHAS"1,T/FINjiL IMCTIQN <br /> i INSPECTION BY DATE INSPECTION BY ATE <br /> 07 <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INS <br /> E H 1426 E 4/72 IM <br />