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' SAN JOAQUIN LOCAL IEALTH DISTRICT <br /> FOR ` FFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.7L S, o <br /> g�s5 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ''ISSUED Date Issued 5 -30-7 2-- <br /> (Complete <br /> (Complete In Triplicate) <br /> Application is hereby, m de 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 S'O 4 /3 Lp 44/r. CENSUS TRACT ' <br /> Owner's Name f y`4 / Phone 3/ 7- <br /> Address <br /> Address of [{„t L /{ 4_0g2j c44,1A City , <br /> Contractor's Name R7 f'RaS'S '1/! „4012_ V T C,44)rC&,pLicense # r94fs osPhone <br /> TYPE OF WORK (Check) : NEW WELL "IF DEEPEN/ / RECONDITION /_� DESTRUCTION 17 <br /> PUMP INSTALLATION/ / PUMP REPAIR/ / PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK /?pf SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> f <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial X. Cable Tool Dia. of Well Excavation <br /> J, Domestic/private Drilled Dia. of Well Casing �� <br /> Domestic/public Driven Gauge of Casing /a' <br /> O <br /> Irrigation Gravel Pack Depth,of Grout Seal ,S15' <br /> y <br /> Other Rotary Type of Grout c EA- <br /> Other Other Information ' 4 <br /> • PUMP INSTALLATION: <br /> Contractorf� <br /> Type of Pump 7r'a ec H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP_REPAIR: .F _ � � �/ / State Work Done <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 /> 1 <br /> SIGNED j , ,�./ _ _ _ TITLE <br /> —� RAW PLOT PLAN ON REVERSE SIDE} <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION-ACCEPTED BY �. DATE d <br /> ADDITIONAL COMMENTS: <br /> f PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY � 2 DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 4/72 1M <br />