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"} SAN JOA . > . <br /> •Wit— �.,.�. ..� •--•��_�-.�„ <br /> QUIN LOCAL HEALTH DISTRICT x <br /> FOR OFFICE USE:. " 1601 E. Hazelton Ave.-,. Stockton., Calif.-5 i <br /> Telephones (209 ) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR. PUMP PERMIT Permit No. <br /> —THIS-PERMIT EXPIRES 1 YEAR 'FROM DATE ISSU <br /> I- ED : Date Issued x=-7`3 . <br /> c-o: . -max (Complete In Triplicate) <br /> Application ~is Hereby made -too 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 <br /> MI'-L-I� �// Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 4' y p�G wiG H,oa, r?.GM ' y <br /> NSUS TRACT , 2-03-!Ifo 2 <br /> j <br /> Owner's Name 41-" Phone Z�. <br /> Address r-� >✓ I Io+./n,� a.y ' /a v GI-iPu City <br /> Contractor's Name �IfJNeS��g-v� U�� <br /> License # IZ23yd Phone�Z?- '70 <br /> f - <br /> I ' <br /> TYPE OF WORK (Check) : NEW WELL I% DEEPEN '/% RECONDITION /-7 DESTRUCTION /`7 <br /> PUMP INSTALLATION A/ PUMP REPAIR -/ / PUMP REPLACEMENT <br /> Other / I I <br />• - oC 3 <br /> DISTANCE TO NEAREST: SEPTIC -.TANK SEWER LINES _ PIT PRIVY <br /> SEWAGE 'DISPOSAL FIELD <br /> � ---- CESSPOOL/SEEPAGE PIT � OTHER <br /> INTENDED USE TYPE OF WELL <br /> IndustrialCONSTRUCTION SPECIFICATIONS <br /> Cable Tool Dia, of Well Excavation <br /> Domestic/private I Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> _ 1/ Irrigation { Gravel Pack Depth of Grout Seal <br /> Other y Rotary Type of Grout . <br /> Other Other Information <br /> 1 <br /> PUMP INSTALLATION: <br /> Contractor <br /> Type of Pump r2vG S l�dti.! a�vo ✓ri ��� H.P. _ 1�6' <br /> PUMP REPLACEMENT: State Work Done L� 2Sh`P <br /> PUMP REPAIR: /�/ State Work Done J <br /> .DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply withiall 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 <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY #, <br /> PHASE I ` <br /> APPLICATION ACCEPTED BY DATED <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE-III/ INAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION IPRIOR TO GROUTING AND FINAL INSPECTION. <br /> IvOl <br /> E H 1426 <br /> 4/72 1M <br />