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I Na' St�SCl(,AQU1N LOCAL UEALTH DI>TRIC- <br /> FOR GFFIC / 1601 T. llazcltcn Ave. , Stockton, Cal—ff. <br /> 1 / TeL-phone: (209) 466-6781 <br /> A� LTCATIO.N FOR WELL CONSTP!TCTION OR ITL' PEKMIT Permit No. <br /> ,/ THIS PERMIT EXPIRES 1 YEAR FROM DATE 1SSUED Date Issued/4 <br /> ,.:oi%plete In Triplicate) <br /> Application is hereby made to the San Joaquin Local •iealth District for a permit to consrruct <br /> _ and/or install the work herein descr:-bed. This application is made in compliance with San :Daquir. <br /> County Otdinance No. 1862 and the Rules and Regulariois of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 3541 Stevenson CENSUS TRACT <br /> Owner's Nara Ancrew Card Phone 455 9508 <br /> Address _ 35+1 Utcvenson _ City Stockton <br /> Contractar's Name J. A. ihvl'.iamer Co. License ll 272 703 Phone 477 1358 <br /> TYPE OF WORK (Check): NEW WF-'.1. ,!j% DEEPEN /% RECON?DITION / / DESTRUCTION /-] <br /> PUMP INS":AI LATION / / i'UP'0 REPAIR ! % PUMP REPLACEMENT <br /> Other / f — <br /> DISTANCE TO NEAREST: SEPTIC ':'ANF 5TTT• SdWER LIQ ES 70f't•PIT PRIVY <br /> SEWA`',E DiSPUSAL FLEL:D _ -- CESSPOOL/SFEPAGF. PIT OTHER <br /> y - INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Too' Dia. of Well Excavation lU inc <br /> + Domestic/private Driiled Dia, of Well Casing :ncr: _ <br /> Domestic/public Driven Gauge of Casing .TY9 <br /> Irrigation Graved Pack Depth of Gtout Seal �--O ft. <br /> _ Other _ *++ Rotary Type. of Grout Ce-lent <br /> Other Other Information <br /> PUMP INSTALLATION_: Contractor <br /> Type of Pump <br /> PtfmP REPLACEMENT: / ! State Work Done <br /> PUMP REPAIR: W- / <br /> / State Work Doyne <br /> ESTRUCTION O 1e is ter 0 ners resoon ibil' / Approximate Dep h <br /> rite Material and Proced re <br /> I hf%� agree [o comply with ail awr and reg, tion, of t e San -oaqui Local Health D t <br /> and the State of California pertaining to or regulating well construction. Within F! EN <br /> after completion of my work or a new well, I will furnish the San Joaquin Local Healrh Dis rict <br /> WELL DRILLERS REP,-'RT of the well and notif; the-i before putting the well in use. The above <br /> information -a true to the best of my knowledge and belief. <br /> SICNED //��.{Vr�.QC.�.`_ _ TITLE -- <br /> TT (DRAW PLOT PLAN ON REVERSE SIDE) <br />- FOR DEPArtT*."-'NT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY d� roc�� , _. DATO <br /> ADDITIONAL COMMS"TS; <br /> P X--'GROUT INSPECTION PKAS I/ PECTION - <br /> INSPECTION BY / DATE i - INSPECTIOF BYE <br /> CALL FOR A GkOUT INSPECTION PRIOR TO GROUTING AND FINAL INSN <br />-- E H 1426 % �, -7/72 1M <br />