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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR.•UMCE USE: 1601 E. Hazelton Ave. , �Stockton, Calif. <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 Z_t0- <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued q- 13. � � <br /> (Complete In Triplicate) <br /> Application isreby made to the San Joaquin Local Health District for a permit to construct <br /> and/or install t e 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 I.� Z �,,`.y,. CENSUS TRACT <br /> Owner's Name , ,Q ..., Phone 7z <br /> Address 6 2tir..� City SAi-c�,(C <br /> Contractor's Name coo License # 71 ZOz Phone 2- <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN /_/ RECONDITION /_/ DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR NT <br /> / / PUMP REPLACEME /_7 <br /> Other /_7 — — <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT 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 <br /> Domestic/public Driven Gauge` of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal SlJ <br /> Other Rotary Type of Grout 4�-'Sar/_-A_ <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> ,DESTRUCTION OF WELL: Well Diameter C, Approximate Depth O(J <br /> Describe Material and Procedure C / <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 FIF'T'EEN 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 s true o the best of my knowledge and belief_._ <br /> SIGNED / l� TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I �} <br /> APPLICATION ACCEPTED BY 1/U_: _ ._ V CYT,(! --- - DATE 1 1 <br /> ADDITIONAL COMMENTS: <br /> PHASE-II -GROUT -INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTIOZkBY DAxE. INSPECTION BY DATE <br /> CALF A !' INS PRI R TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 /}� () t ,N► 4/72 iM <br />