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t SAN JOAQUIN LOCAL 11XALTH DISTRICT <br /> FOR OFFICE USE: "f` 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> ! _ PLICATION FOR WELL CONSTRUCTION` OR PUMP PERMIT Permit No. Z-7 7 <br /> HIS PERMIT EXPIRES 1 YEAR-FROM DATE "ISSUED Date Issued -]. Z'7--7 ?� <br /> (Complete In'Triplicate) / 3� -( <br /> Application is hereby ma a to the San JoaquinLocalHealth 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 /> i JOB ADDRESS/LOCATION QIQP i rn IC b o v��►e,r� S�+Q.. o�.{i CENSUS TRACT <br /> Owner's Name Phone <br /> iAddress � ,� L1 u�: +. u - City . .ciy' <br /> 7 <br /> Contractor's Name ��� �,��-�'. �_/� '' �J _ License # 14:7.373 Phone <br /> TYPE OF WORK (Check) ; NEW WELL f / DEEPEN / / RECONDITION /_/ DESTRUCTION /_7 <br /> PUMP INSTLATION PUMP REPAIR / PUMP REPLACEMENT /� <br /> AL <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 I Cable Tool Dia. of Well Excavation <br /> { a( Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> X Irrigation Gravel Pack Depth of Grout Seal <br /> i Other Rotary Type of Grout _ <br /> l Other Other Information T4 <br /> b <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> { <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: L f State Work Dane <br /> ,pESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> i <br /> fi 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 co of my work n a new well, I will furnish the San- Joaquin Local Health District a <br /> 4 WELL D LERS RE RT of the to 1 notify them before putting the 11 in use. The above <br /> inform tion. s tx to t o a f y knowled e d belief. _ <br /> fi SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SID <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I � <br /> APPLICATION ACCEPTED BY DATE ' <-' Z. -7- <br /> ADDITIONAL <br /> 1-ADDITIONAL COMMENTS: <br /> PHASE Il GROUT INSPECTION PHASE I I/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> I CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSP ON. <br /> E H 1426 4/72 IM <br /> `-W <br />