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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: r 1601 E. Hazelton Ave. , Stockton , Calif." <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED , Date Issued g�j��_�3 <br /> .=/J (Complete In Triplicate) X03 - /2-o ,�!/�'-T <br /> Application-is hereby made to the San Joaquin Local health Distract for a permit to construct <br /> and/or install the work herein described. This application is made in with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> Dj M j C)f 4 L4-S X3.7 <br /> JOB ADDRESS/LOCATION S,v+wa (�,U(2n/¢<j, /V0,1L y 4,6 4V ,Va iPoaENSUS TRACT <br /> i <br /> Owner's Name /m f�ti� rid � h jam, S P/C Cff(si Q�LN/p1 Phone -fq 0 L 2, 7 ' <br /> -- ---• I <br /> Address �AAI2:1A 410-,V"f/VV 2D City <br /> Contractor's Name %/f�✓/SC�/��� i�i✓J� License # /7 93YO Phone Tu-.15;g2-7 <br /> TYPE OF WORK (Check): NEW WELL-/—/ DEEPEN '/—/ RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION r117PUMP REPAIR/ / PUMP REPLACEMENT J <br /> Other / / J i <br /> (ro i <br /> DISTANCE, TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY (� j <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br />' INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS i <br />` Industrial �� Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing _ <br /> ✓ Irrigation Gravel Pack Depth of Grout Seal <br /> i <br /> Other Rotary Type of Grout ' <br /> Other Other Information <br /> PUMP INSTALLATION: Contractors <br /> Type of Pump "o-e2 i-e4.5 H.P. <br /> PUMP REPLACEMENT: State Work Done _r �- 2 <br /> ,� t1 iaL- 8 f� s4 G.� a ! j <br /> PUMP REPAIR: / / State Work Done SEpL f)o - IV(� SQ�ND1l� <br /> rrc17: -r-: <br /> ESTRUCTION 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 well and notify them before putting the well in use. The above <br /> ' information istrueto the best of my knowledge and belief'. <br /> SIGNED !�. �° - � L� TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I �� <br /> APPLICATION ACCEPTED BY / DATE Y/ <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTIOITP S I F AL INSPECTION <br /> INSPECTION BY -DATE INSPECT BX DATE _Z Zr <br /> - <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 4/72 1M <br /> 39 <br />