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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 /> IC PLIATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. -7 L. 4/Z <br /> gy730 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 5-16 2- <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 /> 30B ADDRESS/LOCATION �.3 +� �,,r,T CENSUS TRACT S'7fi 7 <br /> Owner's Name Phone <br /> Address - ! Ll `7 City ' <br /> Contractor's Name �.� o�-/.�ry'1 License # Phone <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN /_% RECONDITION /_/ DESTRUCTION /- <br /> PUMP INSTALLATION 1 PUMP REPAIR / I PUMP REPLACEMENT /7 <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK S�o SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD SO CESSPOOL/SEEPAGE PIT Zg2:� — 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 M <br /> Domestic/public }Driven Gauge of Casing ] � <br /> Irrigation Gravel Pack Depth of Grout Seal S16 <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> -yc•�- <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 /> informatiae to the�est of my knowledge and belief. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE '�� 4k"-27 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY /> DATE ,5= / <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 4/72 1M <br />