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SAN JOAQUIN LOCAL HEALTH-DISTRICT � <br /> FOR OFFICE USE 1601 E. Hazelton Ave. , Stockton, Calif. ` <br /> Telephone: (209) 466-6781 z <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No:.,,3- <br /> THIS, PERMIT EXPIRES 1 YEAR .FROM DATE ISSUED Date Issued 3.�Q2 77j j <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 />'f q 4 JOB ADDRESS/LOCATION �_� 7 ! 4 CENSUS TRACT S 4 7 <br /> Owner's Name Z4n..tl G, ' l/} 47� ,/ _ _ Phone <br /> Address a/ /•9.1'�'`�/ City <br /> �! sr/. <br /> Co�-tlyrs Nage r .�s1� .,�, Lf�` �` x LicensPhone <br /> TYPE`OF WORK (Check) : NEW WELL / / DEEPEN /_/ RECONDITION /_/ DESTRUCTION /_7 <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other <br /> r <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 <br /> Industrial r Cable Tool Dia. of Well Excavation f " _ ash <br /> Domestic/private ! Drilled Dia. of Well Casing �' y <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal S"J ' <br /> Other 3 Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION. Contractor <br /> Type of Pump - H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done _ <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 ORT of the w 1 and notify them before putting the well in use. The above <br /> information is ue to best of my knowledge and belief. k <br /> SIGNED Q TITLE <br /> (DR4 LOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I OO <br /> APPLICATION ACCEPTED BY �J�1.�rL� _ _ DATE <br /> ADDITIONAL COMMENTS: <br /> �/ 6 ,� INSPECTION BY <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> ' INSPECTION BY DATE �"�� ._. _ DATE � -/2--7.3 <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />