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SAN JOAQUIN LOCAL HrAL`CU DISTRICT <br /> FOR OFFICE USE: 1.601 E. Hazelton Ave: , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> PLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 Z - f Lo <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued Z,-- <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 Regulations of the San Joaquin Local'Health District. <br /> .TOB ADDRESS/LOCATION � <br /> _ �� � (rt�rf,,� CENSUS TRACT <br /> Owner's Name ��-v- .._..._ Phone - 3 <br /> Address 3-- o City <br /> Contractor's Name License # &V �5 (- Phone <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN / / RECONDITION /-7 DESTRUCTION /7 <br /> PUMP INSTALLATION { { PUMP REPAIR/ / PUMP REPLACEMENT /-7 <br /> Other { / — <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 X Cable Tool Dia. of Well Excavation .16 <br /> �, Domestic/private Drilled Dia. of Well Casing G <br /> Domestic/public Driven Gauge of Casing /,L- l — <br /> Irrigation Gravel Pack Depth of Grout Seal -d-G l 1 <br /> Other Rotary Type of Grout �� <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / 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 /> SIGNED �[ C- TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I o �F <br /> APPLICATION ACCEPTED BY L/cLl�'.l.Z�',h'.T DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE-III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE -TZ-_7 <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 , ,. 4/72 1M <br />