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/ 1 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFi%,: USE: 1601 E. Hazelton Ave., Stockton, Calif. <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. _ i 341 <br /> 7s <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED nate Issued LL2,g_71 <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 Joaquin, <br /> County Ordinance No. 1862 and the Rules and Regulatic+n3 of the San Joaquin Local Health District. <br /> J08 ADDRESS/LOCATION 2:-,A/R/E, c J c' c < <..c-P, CENSUS TRACT 8 '� <br /> Owner's Name c 'y I Tf� Phone <br /> Address s b . ... City 4r-,4 14De ,- .A -1 <br /> a Contractor's game 4 License ! r r i Phone 7.,f- _s t- <br /> { TYPE OF WORK (Check): NEW WELL J DEEPEN /-7 RECONDITION /-7 DESTRUCTION /7 <br /> PUMP INSTALLATION /W PURI REPAIR / / PUMP REPLACEMENT /7 <br /> t Other — <br /> i <br /> DISTANCE TO N^•AAEST: SEPTIC TANK L. t, - SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial X Cable Tool Dia. of Well Excavation S`d' 3 <br /> Domestic/private Drilled Dia. of Well Casing ' <br /> ' Domestic/public Driven Gauge of Casing Jz <br /> Irrigation Gravel Pack Depth of Grout Seal s`a ' <br /> Other Rotary Type of Grout 6: p- }` <br /> Other Othrr Information <br /> PUMP INSTALLATION: Contractor .1z -,tC <br /> Type of Pump - H.P. N' <br /> PUMP REPLACEW-.NT: / / State Work Done <br /> PUMP REPAIR: / / State Work Dora i <br /> .2ESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure i <br /> i <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 /> SIGNED GLs. .t�-c4 TITLE <br /> DRAW PLOT PIAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY��� 4 DATE / ! 1� Z <br /> ADDITIONAL COKIENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY '� . DATE INSPECTION BY , DATE 3- Q •L .' <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />