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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOT'. "OFFICE; USE: /1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone. (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7.2:_/D 70 <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 an the Rules and Regulations of the San Joaquin Local Health District. <br /> "1 LQ b 2r v-1- al-f i 6-N ,�4- <br /> JOB ADDRESS/LOCATION4 fJ CENSUS TRACT [ Zit-f 90j <br /> D+Fre e. 'il2v S".30 Fj6 <br /> Owner's Name ; � /j, z __ _ / Phone4o;prt At�q-,f ' - <br /> L" <br /> t 3 7 F 1- <br /> Address -- -- J'7�A�X/ Ir'� dp L 4)3 rs C7 City <br /> Contractor's Name Al0't-Gle ({' License #,A-47—ony Phone ! <br /> TYPE OF WORK (Check) : NEW WELL 1>4� DEEPEN '/ / RECONDITION f-1 DESTRUCTION /- <br /> PUMP INSTALLATION / / PL`MP REPAIR / / PUMP REPLACEMENT /- <br /> Other / J <br /> N <br /> DISTANCE TO NEAREST: SEPTIC TANK � SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSALTFIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation u <br /> Domestic/private Drilled Dia. of Well Casing - �} •� <br /> Domestic/public Driven Gauge of Casing AUG / C3 <br /> Irrigation Gravel Pack Depth of Grout Seal <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 U-PAIR: j J State Work Done <br /> ,DFRTRUCTION 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 any work on a new well, I will furnish the San Joaquin Local Health District <br /> WELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> informatio t ue to the best of my no edge and belief. <br /> SIGNED t TITLE --Ad ��P� <br /> ZZ (D PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE /-QD-7- <br /> ADDITIONAL COMMENTS: - <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTIO . <br /> E H 1426 5/73LX <br />