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G ;f SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 NNED <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.7� <br /> l <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED Date Issued 6 -23 <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 Joaquil <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District.- <br /> JOB ADDRESS/LOCATION st corner of ack lone & Baker Fioad6ENSUS TRACT <br /> Dwne r's 'Name _ pan Brand stg.d­ Phone <br /> AddressBaker Hod _ City Stockton <br /> lontractor's Name menden Sertlee PLIm S License # AppliedPhone $$ 6 8 <br /> CYPE OF WORK (Check) : NEW WELL / / DEEPEN /7 RECONDITION /7 DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT &-7 <br /> Other /J -- <br /> )ISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES PIT PRIVY <br /> Unknown SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> (Replaced old pump) d <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 /> Domestic/public Driven Gauge of Casing <br /> I,,-- Irrigation _ Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> - Other Other Information <br /> 'UMP INSTALLATION: Contractor Li ndpnn S Arvi ea .pDpS__ <br /> Type of Pump _Line3�arblne <br /> _ H.P. 40 <br /> ,UMP REPLACEMENT: / / State Work Done <br /> 'UMP REPAIR: / / State Work Done <br /> e-ESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> nd the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> fter completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> ELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> nformation is true to the best <br /> of my knowledge and belief. <br /> IGNED �] .. i-Q�: TITLE Partner <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> RASE I <br /> PPLICATIQN ACCEPTED BY <br /> D A T4 feA Y'� <br /> DDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHA N INSPECTION <br /> NSPECTION BY .�_ DATE INSPECTION BY DATE -Z - <br /> r, CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INS N <br /> E H 1426 7/72 1M <br />