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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6.781 <br /> !O <br /> F <br /> ICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7z--5-SEY <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 6- q 7 Y <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 2 t E � �A CENSUS TRACT <br /> Owner's Name _ 12k— !v X12-�L�' .. ;,,....,,..,,_ Phone 4oeA - /,9- <br /> AddressOEi r", ®3 ' _..... .,_ City <br /> �. _ - <br /> Contractor's Name License # Phone `X;,1-- 747 <br /> Me-U WQr Y' A,p f/!n�r <br /> TYPE OF WORK (Check) : NEW WELL/Of DEEPEN /—/ RECONDITION /_/ DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER V <br /> INTENDED USE. TYPE OF WELL CONSTRUCTION SPECIFICATIONS \� <br /> Industrial Cable Tool Dia. of Well Excavation U <br /> �X 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 <br /> Other Other Information ' <br /> PUMP INSTALLATION: Contractor ��dhJ�P�I �?rt,, 4SL <br /> Type of Pump - �,a/, ,�^-�,�!`'_� H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done A4 t/tc 7 V e AO 0,/ <br /> V <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 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 kj r TITLE <br /> f <br /> (DAA,UT PLOT PLAN ON VXVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I � ` <br /> APPLICATION ACCEPTED BY _ ► �ou- _ -----l------ DATE [I-7 [ 791 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY <br /> f.�_&k_(rL DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> EH�1426 „ ;_ r Jql� �� 4/72 1M <br />