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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 /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.7S_ <br /> ti <br /> �Q THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued rD.-2,7s <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 de in compliance with San Joaquin <br /> County Ordinance No. 1862 a the ales lation o San Jo uin Local Health District. <br /> JOB ADDRESS/LOCATI �2 ��. �L. titi1 @}vct2 ^.lit ENSUS TRACT <br /> Owner's Name C y r Com' -� Phone <br /> City � ugz ,�- <br /> Contractor's Name a � L t-It License # ,�2774g1Phone <br /> TYPE OF WORK (Check) : NEW WELL /V DEEPEN /_-7 RECONDITION /-7 DESTRUCTION /'7 <br /> PUMP INSTJ'LATION / / PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINY.S PIT PRIVY <br /> SEWAGE DISPOSAL FIELD / r; CESSPOOL/SEEPAGE PIT OTHERll <br /> Ski <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation 7b S70 - Q <br />_ Domestic/private Drilled Dia. of Well Casing s <br /> Domestic/public Driven Gauge of Casing .e'er <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout - fl.yL. i <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor r' <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 f my knowledge and belief. <br /> SIGNED Z; /^ 6�� =f 4eA r <br /> TITLE <br /> (DWPLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE f7 <br /> ADDITIONAL COMMENTS: A2 '7% - <br /> PHASE II GROUT INSPECTION 7PHASE III/FINAL N ECTION <br /> INSPECTION BY DATE /�/-2 INSPECTION BY DATE 10 <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. ;;.. <br /> E H 1426 7/72 1M,/� <br />