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7-;64 SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 601 E. Hazelton Ave. Stockton <br /> Cal.if. <br /> Telephone: (209) 466--6781 7� tel/P <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7,7-.�d 701"' <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED Date Issued L <br /> (Complete In Triplicate) 20&— 05'0--pg 7L <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 /> JOB ADDRESS/LOCATION /2 C- g& CC NSUS TRACT <br /> Owner's Name & A 1`, <br /> Phone 3r� <br /> Address _ /d-•- I Iy /? -P City ./ <br /> Contractor's Name 16-IX-1 Al IV License # Phone <br /> TYPE OF WORK (Check) : NEW WELL 9 DEEPEN /_7 RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION �/ PUMP REPAIR /—/ PUMP REPLACEMENT /_7 <br /> Other / / — — <br /> DISTANCE TO NEAREST: SEPTIC TANKcS� SEWER LINES PIT PRIVY _ <br /> SEWAGE DISPOSAL FIELD_3 8 t CESSPOOL/SEEPAGE PIT OTHER { <br /> INTENDED USE TYPE OF WELL <br /> CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation P(� <br /> Domestic/private . ~ Drilled Dia. of Well Casing <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 /Z-R Z ,u,4 <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done e4l6 ,A-el <br /> PUMP REPAIR*. / / State Work Done <br />.RESTRUCTION OF WELL: Well Diameter <br /> - •• aJV1�-- 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 work on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS PORT of the well and notify them before putting the well in use. The above <br /> information i true to the best of my knowledge and belief. <br /> SIGNED C-1 <br /> --- TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY a , (} DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />