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,.. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT '` <br /> FOR OFFICE USE: °1601 E. Hazelton e. , Stockton, , Calif. ` <br /> TelJ'phone: (20 )' 46§-6781 r <br /> APPLICATION FOR WELL• CONSTRUCTION OR PUMP PERMIT Permit No. 1 <br /> -THIS PERMIT EXPIRES. 1 YEAR FROM DATE ISSUED Date Issued <br /> .:a (Complete Tri Triplicate) <br /> Application -is hereby madey,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 LocA1 Health District. <br /> JOB ADDRESS/LOCATION Iy Roo- ,c� � 1v � a CENSUS" TRACT - <br /> t <br /> Owner,'s Name Phone " yG� 6,6799 <br /> P <br /> � <br /> Address _ Y G G�f �� /`7-y 1�7. - =- ---- City , LZI <br /> Contractor's Name License # Phone <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN_/_/ RECONDITION /_/ DESTRUCTION /-7 <br /> PUMP INSTALLATION "/ / PUMP REPAIR / / PUMP REPLACEMENT IST <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK -=— SEWER LINES 4-6 PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> l <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 /> <k <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump ei1 inery1Bt,6T_ H.P. <br /> " PUMP REPLACEMENT: I I :'.".State Work Done _ <br /> PUMP REPAIR: / / � State Work Done <br /> M <br /> DESTRUCTIONOF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I 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 TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> PE r <'o"� 9 o OR DEPARTMENT USE ONLY <br /> `:`�APPLICATIO ACCEPTED BY DATE Z <br /> "ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A ZOUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION." <br /> E H 1426 `, 4/72 1M <br />