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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFIC USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. -7Z-- q2-P <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 10-3 77/ <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 .9L� CENSUS TRACT <br /> Owner's Name -,JDXh / Ane A 11-5 Phone <br /> Address Z9 z67,0-'.77l5 461e City,5 � <br /> Contractor's Name 6494V1.& 4-Ar4� 1!�)_,-_x a License #/% Phone <br /> TYPE OF WORK (Check) : NEW WELL /-7 DEEPEN / / RECONDITION /-7 DESTRUCTION /-J <br /> PUMP INSTALLATION /Y/ PUMP REPAIR / / PUMP' REPLACEMENT XT <br /> Other �7 <br /> )ISTANCE 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 /> 'UMP INSTALLATION: Contractor <br /> Type of Pump - 421 .40(4-EY H.P. <br /> 'UMP REPLACEMENT: / / State Work Done j" <br /> 'UMP REPAIR: - /% State Work Done <br /> iESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> .nd the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> fter completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> ELL DRILLERS REPORT of the well and notify them before putting the well in use . The above <br /> nformation is true to the beat of my knowledge and belief. <br /> IGNED TITLE ,� <br /> (DRAW PLOT PLAN ON REVERSE SI6E) ' <br /> FOR DEPARTMENT USE ONLY <br /> RASE I / <br /> PPLICATION ACCEPTED BY DATE l O <br /> DDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PRASE6IFINAL INSPECTIO <br /> NSPECTION BY DATE INSPECTION BY DATE f � <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTIO . <br /> 9 H 1426 7/72 1M <br />