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SAN JOACUIN 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? .� <br /> i <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued ,•Z 7'7Y <br /> (Complete In Triplicate) ! <br /> Application. is her y 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 CENSUS TRACT <br /> Owner!s.:Name` L" ' JOS l��iV T � 4 — Phone <br /> Address ' City <br /> License # Phone d <br /> Contractor s Name J D.�ci �#- az - i <br /> TYPE OF WORK (Check) : NEW WELL I DEEPEN/ / ; RECONDITIO' /Y/ DESTRUCTION <br /> PUMP INSTALLATION I I PUMP; REPAIR If PUMP REPLACEMENT I� <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 Wk. 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 „ <br /> Type of Grout <br /> - <br /> Other Other Information - `"tk <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> i <br /> PUMP REPLACEMENT: F= / / State Work Done <br /> PUNA' REPAIR: _ /� State Work Done _6 12 10 W e Lac-.oa a_U /� %1' '�rC ZI <br /> .DESTRUCTION OF WELL: Well Diameter Approximate Depth l' <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 /> I 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. Tte above <br /> 6 <br /> information is true to the best of my knowledge and belief. <br /> oe <br /> SIGNED <br /> TITLE <br /> (DRAW PLOT P_4A.,7-JC A==� <br /> LAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> k PHASE I <br /> DATE <br /> APPLICATION ACCEPTED BY Z <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTI . <br /> E H 1426 4/72 1M <br />