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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Haz-elton` Ave. , Stockt.oi-i, Calif. <br /> Telephone:: "..�(209). 46b=67.81 <br /> PLICATION FOR WELL CONSTRUCTION,'..OR PUMP PERMIT Permit No. � <br /> THIS PERMITIRES.':1`,YEAR"FROM�DATE',,ISSUE0 ` 'Date'Issued`' (`36'72 , <br /> .,o(Complete Ing-Tri"ip3icate) <br /> Application;is:hereby,ma e:to the c$anR;Joaquin toeal, Hdalt. Da strict `f or�'a>permit to' construct <br /> y rein described. This-•:application is=made-'in -compliance with,San Joaquin <br /> and/or install the work h <br /> Count Ordinance Regulati'on.s of 'the.:San 3°oaquin Local'Health 'District: <br /> r{i'a: il'a z.i• . .� tf�CS. "e't". c3itr.,¢ _, < x.�'.. ;;.:rs- r: 4 ,.... -. " i`' ".. r, .. a , <, � . <br /> JOB ADDRESS/LOCATION .1/7C A(QeZdr,&,g&L)wj,2 L .._,­,,:CENSUS'TRACT l <br /> C. <br /> Owner's,:Name`' `�_1.Aui;PFNCE °: ' C.F:: 'Lr Y, .Phone <br /> Address city fo: ?b„l- <br /> R c, <br /> Contractor's Name SAME' As etaN�R License # — Phone AB�� <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN RECONDITION RECONDITION /_7 DESTRUCTION , <br /> PUMP INSTALLATION/ / PUMP REPAIR '/ / .PUMP REPLACEMENT /7 I <br /> Other. / <br /> A/DAp�ryu <br /> DISTANCE TO NEAREST: SEPTIC- TANK ,p�T 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 <br /> Domestic/private Drilled Dia. of Well Casing <br /> p - g <br /> Domestic/public Driven Gauge of' Gasin 1 <br /> Irrigation Gravel Pack Depth of.Grout Seal <br /> Other Rotary Type of Grout <br /> p&WE&Q0640 OF Other Other Information <br /> PUMP INST ATION: _ Contractor <br /> Type of Pump H.P, <br /> PUMP. REP EMENT: / / State Work Done ` <br /> PUMP AIR: / / State Work Done <br /> ,DESTRUCTION OF WELL: . Well Diameter /0101 Approximate Depth GjS e <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. j <br /> SIGNED TITLE ©U2 NE A.- <br /> (DRAW-P—Lff PLAN ON REVERSE SIDE) ` <br /> FOR DEPARTMENT USE ONLY j <br /> PHASE I <br /> APPLICATION ACCEPTED BY s DATE CJ <br /> ADDITIONAL COMMENTSr -- <br /> PHASE II GROUT INSPECTION PHA F INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A. GROUTIINSPEC_TION_PRIOR_TO GROUTING' AND FINAL INS <br /> E H 1426 4/72 IM s <br /> i <br />