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LOCAL HEALTH D i S�T <br /> FOR~OFFICE USE: 1601 E. azelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6781. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 1-7 -/O G !� <br /> 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 /> 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 -V-tiT,L &Z 7- ' ? CENSUS TRACT <br /> cx. <br /> Owner's Name Phone <br /> C <br /> Address City <br /> Contractor's Namet-1X,-j - License # f �!�� Phone <br /> TYPE OF WORK (Check) : ' NEW WELL / / DEEPEN/ / RECONDITION /-7 DESTRUCTION /`7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /? <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 Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casings _ <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth;of Grout Seal f3 � <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 TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> F R DE RNT USE ONLY <br /> PHASE I7- ,17- 70-, <br /> APPLICATION ACCEPTED-BY-- 6107;07 3 DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE 11 GROUT INSPECTION PHASZ III/FINAL INSPECTION <br /> INSPECTION BY t DATE _7.:�9/-?_?- _ INSPECTION BY DATE /0-26-77- <br /> CALL <br /> 6-72CALL FOR A G T INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 4172 1M <br />