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SAN JCT QUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: ! 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> AP LICATION FOR WELL.CONSTRUCTION OR PUMP PERMIT Permit No. 7 L-7 G <br /> IS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> -(Complete In Triplicate)' <br /> Appli io is hereby made to theSanJoaquin 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 OPL c�.-ENSUSfTRACT/'/OZ- <br /> JOB 6 tZ U %u Af EA5 T q/,AILRo,4DTaAc/zCENSUS TRACT <br /> Owner's Name G E' %E"A' f�/e/94 J Phone 3 G 3 3 <br /> Address 3 5" / %ZE; `e�Al A I/ City �v Df GA c CF <br /> Contractor's Name r fiyg•� License # x 6 S- kiione W x _ gr 1 z <br /> A <br /> TYPE OF WORK (Check) : NEW WELL /F DEEPEN /_7 RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION/ / PUMP REPAIR/-7 PUMP REPLACEMENT /-7 <br /> Other / 7 <br /> DISTANCE TO NEAREST: SEPTIC TANK et>e 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 Casing i <br /> Domestic/public Driven Gauge of Casing <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 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 �f %C.¢ f' ��, ftr .TITLE <br /> (DRAW PWY PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY \ DATE �$-' - <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPE TION PHASE II FINAL INSPECTION <br /> INSPECTION BY E DATE INSPECTION BY DATE ,?- <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. W nt <br /> E H 1426 4/72 1M <br />