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' SAN JOAQUIN LOCAL IIEALTH :DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton- Ave.", Stockton, Calif. K� <br /> Telephone: (209). 466-6781 <br /> PLICATION FOR WELL CONSTRUCTION'OR PUMP PERMIT Permit No. Z- $ 6 O <br /> THIS PERMIT EXPIRES 1 ;YEAR FROM DATE 'ISSUED- Date Issued g - 11-17/ <br /> (Complete In Triplicate) <br /> Application is .h -eby-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 /> ' . � CENSUS TRACT <br /> JOB ADDRESS/LOCATION °L +C' 12` - Y .2 L <br /> r : <br /> Owner's Name--i LZ fi` f,A)Al.i�- - T 61ff-I1`A TTI-7., _ Phone ' <br /> Address City <br /> 1 Contractor's Name L /T License # GGG Phone " <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN -/7 RECONDITION / DESTRUCTION / <br /> PUMP INSTALLATION PUM`'i REPAIR /' / PUMP REPLACEMENT /7 <br /> Other <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 <br /> Other Rotary Type of Grout <br /> Other Other Information ' <br /> PUMP INSTALLATION: Contractor Zl C�1 <br /> Type of Pump H.P. <br /> t <br /> 3 <br /> PUMP REPLACEMENT: State Work Done <br /> PUMP REPAIR: / State Work 'Done <br /> ,DESTRUCTION OF WELL:: Well Diameter F 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 /> i and the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> after completion ofjmy 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 /> h FOR.DEPARTMENT USE ONLY � <br /> PRASE I �: . w..w.. .._. T - - '� ;. _ _ .i .. DATE 7 <br /> APPLICATION ACCEPTED BY c �� <br /> ADDITIONAL COMMENTS: <br /> k PHASE II GROUT INSPECTI AT" <br /> / INSPECTION <br /> INSPECTION BY DATE INSPECTION BY E <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL IN <br /> E H 1426 4/72 1M <br />