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SAN JOAQUIN LOCAL HEALTH bISTRICT <br /> LR0OVk-10E USE: t 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ZL__2_Z 7 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -77j. <br /> (Complete In Triplicate) <br /> Application is hereby made- to the San Joaquin Local Health District for a permit to construct <br /> and install the work herein described. This .application is made in compliance with San Joaquin <br /> County Ordinance No. 862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> 7x�� '� q <br /> JOB ADDRESS/LOCATIO /�{-�✓� CENSUS TRACT <br /> Owner's Name= <br /> Phone <br /> Address ` City. <br /> Contractor's Name � „ License 17 Phone <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN '/ ./ RECONDITION /_7 DESTRUCTION /-7 <br /> PUMP INST LATION 1 / FUMP::REPAIR / / PUMP REPLACEMENT / <br /> Other /% — <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL.FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> t - r I <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS 7711 <br /> Industrial Cable Tool Dia. of Well Excavation 01 <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 ' <br /> L Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: <br /> 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 FTFTEEN: 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 TITLE <br /> (DRAW PLOT PLAN ON ,REVERSE SIDE <br /> F0 MENT USE ONLY <br /> PHASE T ,..- i <br /> APPLICATION ACCE� <br /> DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECT N PHASY, 14I/ AINA-L INSPECT <br /> INSPECTION BY _ DATE _ t5�`--'ZZ�NSPECTION BY DATE —�,�j - t <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H -1426 _ 4/72 1M ,r[ <br /> 1. lc /or <br />