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SAN JOAQUIN LOCAL HEALTH DISTRICT I' <br /> FOR OFFICE USE: 1601 E. Hazelton'Ave.: ,Stockton, Calif. } <br /> Telephone (20:9):!:4.66 .6781 <br /> PLICATION FOR WELL 'CONS`tRUCTION :OR PUMP PERMIT Permit No. 7L-78 v <br /> _-Y.._. m c/ 6 W <br /> THIS PERMIT)EKI?IRES l YEAR. FROri. DAZE'—,'"ISSUED - f`�Date`°Issued 2' '' 7v <br /> '�p� (Complete In T� plxc.a'te) �= . <br /> Applicatiloi6is:3shereby�:made:to [thea San,Joaquin -Loeal -Health 'District: for a-peiini,t to,-conistir iti <br /> and/or install the work herein described. Thi.""b;w'p1=icataon,Ise;made. in'. compl'ianc'e,with:-Sari;,Joaquin <br /> County3,.Ord-inZnee_.-No r 862r�!and-�ithesiRu-:ebs, and-�Regulations,�:o�-,' the :Sail Joaquin-Locak,Health Distract. <br /> 1-10 -mac. ' ✓ <br /> JOB ADDRESS/LOCATION �� � 1 , IV, CENSCTS TRACT _ <br /> i aG;,p „r1("J' c .!_° `+.3i._ ar'��'6??•'": SiY f " :.`!. c.. rz- r'., .:r -�°�i x • f(1 `�' {. i. . '. <br /> 1 Owner.':s--:Nanie` % s' y } ' <br /> Address .. i <br /> Contractor's Name Epaeq amill License # Phone ' Q� <br /> TYPE OF WORK (Check) : NEW WELLALATION <br /> DEEPEN /_/ RECONDITION /_7 DESTRUCTION /_7 I� <br /> PUMP ;INS.T /. / PUMP REPAIR / / PUMP REPLACEMENT : /-7 <br /> ... ..Other / j <br /> DISTANCE TO NEAREST: "SEPTIC TANK A—* SEWER LINES PIT PRIVY " <br /> SEWAGE .DI�SPOSAL FIELD, CESSPOOL/SEEPAGE PIT_ OTHER <br /> ' INTENDED' USE TYPE Or WELL' 'CONSTRUCTION SPECIFICATIONS II <br /> E .. <br /> .industrial. . _. -. Cable ,Tool Dia. ::of ..Well Excavation <br /> Domestic/private pl` Drilled Dia.eof 'Well Casing & 1 '— <br /> Domest.ic/ipiiblic -' - Driven Ga g of Casing <br /> . Irrigation .. ...-_Gravel: Pack Depth_of Grout Seal ` 4 <br /> Other Rotary Type of 'Grout <br /> 'M <br /> .. her Inf o - - <br /> Other Other rmation <br /> -- -fir -- <br /> PUMP INSTALLATION: Conttactor � <br /> Type .of Pump H.P.; . �! <br /> PUMP REPLACEMENT / I State'-Work Done <br /> PUMP REPAIR: / / State Work Done <br /> ,DESTRUCTION OF WELL:. Well Diameter Approximate Depth. <br /> Describe Material and Procedure <br /> I hereby agree to comply waith. all laws and regulations of the San. Joaquin Local Health Distridt <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', Twill furnish the San Joaquin Local Health District a <br /> WELL .DRILLERS .REPORT of the iaell and notify them before .putting the well in use. The above <br /> information is true to the best; of'.my.knowledge and belief.. <br /> t <br /> SIGNED o :_.. TITLE: ' <br /> (DRAW PLOT .PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHA�E I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II -GROUT INSPECTION PHASE III/FINAL' :INSPECTION!I I <br /> INSPECTION BY DATE �INSPECTION BY 4222 DATE -Q?/- ,`z- 1 <br /> CALL, F,OR A G_OUT--INSPECTION PRIOR 'I'0_ GROUTING AND .FINAL, INSP ._.TION:._@�� <br /> E H 1426 4/72 1M <br />