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Gam" SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1641 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7—F- <br /> S' THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> Ind/or install the work herein described. This application is made in compliance with San Joaquin <br /> 'County Ordinance No. 1862 andA�heu, � �tnf,,,th_q San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION . "2M Mr - ,CENSUS TRACT 011- (gb*3y <br /> Owner's Name � f.�7? _ ,CC /, - - Phone -- <br /> Address City W-14 Azlct2z <br /> Contractor's Name Jtom' /�[ License # Phone (p <br /> TYPE OF WORK (Check) : NEW WELL /7/- DEEPEN RECONDITION /_7 DESTRUCTION / <br /> _ <br /> PUMP INSTALLATION /JS/ PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> t Other <br /> ^n <br /> DISTANCE TO NEAREST: SEPTIC TANK)VO SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER "] <br /> S m� <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATION <br /> Industrial Cable Tool Dia. of Well Excavation T <br /> Domestic/private Drilled Dia. of Well Casing lie <br /> Domestic/public Driven Gauge of Casing <br /> T7—__ 'Irrigation Grave, Pack Depth of Grout Seal XV oe <br /> Other Rotary Type of Grout <br /> j Other Other Information I <br /> PUMP INSTALLATION: Contractor ./.�oo�ez `^ <br /> Type of Pump slzaelf,647d H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> J)ESTRUCTION 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 DRILL PORT of the well and notify them before putting the well in use. The above <br /> information t ue to the best of my knowledge and belief. <br /> f SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY G°% DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> ' INSPECTION BY DATE Zj INSPECTION BY _A- DATE <br /> CALL FOR A GROUT INSPECTION 'PRIOR..TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 IM <br />