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dSTRICT <br /> SAN JOAQUIN LOCAL HEALTH D <br /> FOR OFFICE USE: 1601 E. Hazelton Ave., Stockton, Calif. <br /> v � <br /> Telephone: (209) 466-6781 <br /> _ APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS_PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued .-7- -r- <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 appl'cation is made in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regularions of the San Joaquin Lecal Health District. <br /> JOB ADDRESS/LOCATION ,f ) J_C�,r �y i << /2 ��!(�c l l'� �ii/CENSUS TRACT <br /> //i � <br /> / e,h Phone L J 7 <br /> Owner's Name -S 4-�" _ Zzc �1 <<� � �l <br /> Address ---tom ��J 911_• Ice, City r -;�s <br /> i <br /> Contractor's Name f 4:c Licensepry�C, Phone yUij <br /> TYPE OF WORK (Check): NEW WELL /_fi DEEPEN /_% RECONDITION /_� DESTRUCTION !-] I <br /> PUMP INSTALLATION /Lf PUMP REPAIR / / PUMP REPLACEMENT /-7 `-A <br /> Other / / <br /> .,iSTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES PIT PRIVY U1 <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER __ O <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS_ <br /> Industrial Cable Tool Dia, of Well Excavation <br /> Domestic/private Drilled Dia. of Well Caving _ _ cR- <br /> Domestic/public Driven Gauge of Casing __ _ J� <br /> Irrigation Gravel Pack Depth of Grout Seal - <br /> Other Rotary Type c£ Grout <br /> Other Other Infor-ation <br /> PUMP INSTALLATION: Contractus �J_� `�,(1�.,�.-L2 j/"%��•-� ` �� <br /> Type of Pump �� _ H.P. J <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUPIP REPAIR: / State Werk Done <br /> ,DESTRUCTION OF WELL: Well Diarrx-ter 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, 1 will furnish the San Joaquin Local health District a <br /> WELL DRILLERS REPORT of the well anJ notify them before putting the well in use. The abq�e <br /> information is true to the best of my knowledge and bel.icf. ,-JtI <br /> SIGNED TITLE ' OzC <br /> / (DRAW PLOP PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PRASE I !�,. <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: __ <br /> PHASE II GROUT INSPECTiO:! PHA I FINAL INSPECTION <br /> INSPECTION BY DATE — _ INSPECTION BY DATE -a5_X <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPE ON. <br /> F. H 1426 7/72 1M <br />