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7/Fi SAN JOAQUIN LOCAL. HEALTH DISTRICT <br /> 10F.:OF IC.E USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6781 + <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued • _�7� <br /> (Complete In Triplicate) <br /> Application is hereby rude 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 /> V F-.4 f -220--z-71 <br /> JOB ADDRESS/LOCATION - CENSUS TRACT 7 <br /> i <br /> Owner's Name Phone S cg9 33 zr/ ++` <br /> Address <br /> city , 1 <br /> Contractor's Name License # d7 Phone f3k gl_yU <br /> TYPE OF WORK (Check): NEW WELL DEEPEN '/—/ RECONDITION / / DESTRUCTION /-7 –7 <br /> PUMP INSTALLATION / PUMP REPAIR / / PUMP REPLACEMENT / 0 <br /> Other ! / zA <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY �3 <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial X Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing j <br /> Domestic/public Driven Gauge of Casing G1 ' <br /> -- Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information C. <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / j State Work Done <br /> PUMP -tEPAIR: / / State Work Done <br /> i <br /> DFsTRUCTION OF WELL: Well Diameter / Approximate Deth <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 /> i SIGNED R4 94 41. TITLE <br /> j (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: s 75` .�w <br /> ` ' s..,` <br /> r PHASE II GROUT I'ZSPECTION PHASE I I/FINAL INSPECTION _ <br /> INSPECTION BY DATE INSPECTION BY DATE X"g/–'l 3 <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING FINAL INSPECTION. <br /> -_ , , .. C'.7cir e .. �n s.rr , eF/ �s t' ate-, �✓.Y/ �e�� 5/73 <br />