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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6781 <br /> PLICATIQN FOR WELL CONSTRUCTION OR PU1,T PERMIT Permit No. ZZ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 1-7-7-i 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 /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name zCr�;. z�r �tll�� Phone � G�-.7S.7S- <br /> Address U62 _Z1 City -' <br /> Contractor's Name License # Phone <br /> TYPE OF WORK (Check): NEW WELL / / DEEPEN / / RECONDITION /—T DESTRUCTION /`7 <br /> PUMP INSTALLATION / / PUMP REPAIR g/--PUMP REPLACEMENT /—T <br /> Other /_/ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> C1J <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 Gravel Pack Depth of Grout Seal y <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 Donee <br /> f <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 u ?. ,j TITLE <br /> f� (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS III/FINAL INSPECTION - <br /> INSPECTION BY DATE INSPECTION BY &j DATE -72-- <br /> CALL <br /> ZCALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECT& N. <br /> . E H 1426 7/72 1M <br />