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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 11/3_ <br /> /1601 E. Hazelton Ave. , Stockton, Calif. <br /> t v Telephone: (204) 466-6781 7 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 22 VIly- <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 46„� `-�( <br /> 4 (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 Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION A.EFT aFF Lveii G/a«v� , 5".,ry Szoe -A&M Gee <br /> CENSUS TRACT <br /> Owner's Name +3 9Z.esj6o E'2 a [s Phone 3 eq 3 Q-/3 <br /> X77 -006 fp <br /> Address 1 12_ q I n7. &li.�iry. e..iv` City Ld D <br /> Contractor's Name Sil•u Toq P”A,, -eco y _ License # 316-3) Phone 365_9--4_q_71� <br /> . - .�. <br /> TYPE OF WORK (Check) : NEW WELL /_7 DEEPEN / / RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP- REPAIR / / PUMP REPLACEMENT <br /> Other /_7 <br /> DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <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 /> Irrigation ,_ �N, Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout , <br /> ,-i Other Other Information <br /> PUMP INSTALLATION: Contractor } <br /> Type of Pump H.P. i <br /> PUMP REPLACEMENT: i <br /> / state Work Done �LvSL�GC. Scc�Jste.F id/e - K7 Lge efkce wo, + <br />.PUMP.--REPAIR-:,� -.,- t, <br /> S.tate-Work-Done— <br /> JD <br /> one-- <br /> JDESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> ASTRUCTION .,. <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 /> San Joaquin Pump Co. <br /> SIGNED ( TITLE (Division of Seen Joaquin Sulphur ccj <br /> (DRAW PLOT PLAN ON REVERSE SIDE) III N: :ocvci„cnto t, ` <br /> FOR DEPARTMENT USE ONLY LOM, caErar<<in t0a.4-tu <br /> PHASE I <br /> APPLICATION ACCEPTED BYf DATE / - S`2 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE Ij / EIS NAI, INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. . <br /> E H 1426 7/72 1M <br />