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S`N JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 160 . Hazelton Ave. , Stockton, Cale.-. / <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7,1 -77/, <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 7lj /Y-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 Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION a3eZ`% 1/4 y. doP4 �PD to/ CENSUS TRACT <br /> Owner's Name e!5::a +Ie '40, CZE'y� �(j Phone <br /> Address .24City S <br /> Contractor's Name w, License #/ Phone <br /> TYPE OF WORK (Check): NEW WELL / / DEEPEN / / RECONDITION / / DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR /—/ PUMP REPLACEMENT /_7 <br /> Other Y/ �At1bs.•/� q r �� (�o.is �— <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 W <br /> Industrial Cable Tool Dia. of Well Excavation J <br /> _X 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 /> .n <br /> F <br /> PUMP INSTALLATION: Contractor ��t✓ 0.// <br /> Type of Pump r4 0, H.P. /,0 <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: State Work Done _r&4 �jT e��� � }� t nGGY /r'i mlzt <br /> pESTRUCTION 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 knowl ge a belief. _ <br /> SIGNED / 41 � ITLE 4ryS, - <br /> (D W T PLAN ON REV7ERSE SIDE) <br /> OR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY - �J' � _ DATE I0 Z <br /> ADDITIONAL COMMENTS: �� <br /> PHASE II GROUT INSPECTION PHAS II/FINAL INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY DATE 7 7- <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTIO . <br /> E H 1426 7/72 1M <br />