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SAN JOAQUIN LOCAL HEALTH DISTRICT �� ✓ b <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> LICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Z- y <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED . Date Issued 7-12---77-- <br /> (Complete <br /> -fZ-7v(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 Saxe Joaquin Local Health District. <br /> r i <br /> JOB ADDRESS/LOCATION QC" J CENSUS TRACT <br /> G <br /> f <br /> Owner's Name P Phone ' <br /> Address _ Z�,z /`!.cell a City <br /> Contractor's Name ( / / �1//L,f License � ` �`' hone <br /> TYPE OF WORK (Check) : NEW WELL /_ DEEPEN '/ / RECONDITION /_/ DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /7 <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 CONSTRUCTION SPECIFICATIONS Q <br /> __ Industrial Cable Tool. Dia, of Well Excavation O <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing Lr ; <br /> Irrigation Gravel Pack Depth of Grout Seal t' <br /> Other Rotary Type of Grout i A T, <br /> Other Other Information �'�1 -� <br /> I' <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> i <br /> PUMP REPLACEMENT: / / State Work Done <br /> E <br /> PUMP REPAIR: / / State Work Done <br /> ,DESTRUCTION 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 j TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PRASE I J r7 <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT I SPECTION PHASE TAII/FINAL INSPECTION <br /> INSPECTION BYE ATE .. -7 INSPECTION BY DAT, <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTIO ;Cv <br /> E H 1426 4/72 1M <br />