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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 /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 Z-- 17 6 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued /C 7 <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 Joaquir. <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> I JOB ADDRESS/LOCATION ooAl <br /> ie CENSUS TRACT <br /> Owner's Name <br /> Phone 3// 2- <br /> Address <br /> Address 7'Gc.L4 A D City 400/ CAI--f <br /> Contractor's Name �7 ✓✓f�OSK� _ License # /g'4Co�i Phone ` <br /> I TYPE OF WORK (Check): NEW WELL /x/ DEEPEN / / RECONDITION /-7 DESTRUCTION /-' <br /> AL <br /> PUMP INSTLATION PUMP REPAIR /—/ PUMP REPLACEMENT /-7 <br /> Other / 7 --- <br /> DISTANCE TO NEAREST: SEPTIC TANK 6dF SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> t <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial X Cable Tool Dia, of :Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing g <br /> Domestic/public Driven Gauge of Casing .. <br /> Irrigation Gravel Pack Depth of Grout' Seal s-a <br /> Other Rotary Type of Grout <br /> Other Other .Information <br /> PUMP INSTALLATION: Contractor a 6S7G/ <br /> Type of Pump <br /> H.P. <br /> PUMP REPLACEMENT: <br /> / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> ESTRUCTION 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 /> information is true to the best of my knowledge and belief. <br /> SIGNED TITLE4 M <br /> (DRAW T PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE -Y <br /> ADDITIONAL COMMENTS: _ <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY - -- -� z-_ DATE _ INSPECTION ' <br /> BY �/ � DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 <br /> 7/72 1M <br />