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EL i <br /> ()� SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 k <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.,7 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued &) L -2-7- <br /> (Complete In Triplicate) Cd'b-SL/ <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 /> JOB-ADDRESS/LOCATION j� ,e�rJ /��, r�z- _ ,, e,LCENSUS TRACT <br /> Owner's Name - G21� � h!c�l/A_�N - --- - - - Phone 4 zz 9 z C <br /> Address - L/704_1' A leAISN P �� _ City G v/-/ C <br /> Contractor's Name License Phone el6y5S3 <br /> TYPE •OF WORK (Check): NEW WELL /_7 DEEPEN /_/ RECONDITION /_7 DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR PUMP REPLACEMENT /_ <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 <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing , <br /> Domestic/public Driven Gauge of Casing <br /> X Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. p <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / State Work Done <br /> J)ESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply"wi.th 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 Distritt 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 /> SIGNEDLQ� �, - TITLE �. <br /> D W PIM PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED, BY ' ' DATE/ �- 7L <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY 1AW DATE 4Z�f/' ' A- <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />