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z <br /> SAN JOAQUIN LOCAL HEALTH DISTRICTq~,�� <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 -r3-4,115 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 � � <br /> r <br /> THIS PERMIT EXPIRES 1 YEAR FROM ]SATE ISSUED-":- Date Issued ' w23 <br /> (Complete 'Iii 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 /> JOB ADDRESS/LOCATION 3 .2.2 YEd -TkI M/ D�V 6 D CENSU'S TRACT <br /> Owner's Name 64- .-7 Z7- L I Al r-o !j/ __ ... Phone 4(t✓ Z4r ll <br /> _ a <br /> Address L/3A !A(So /2 D City <br /> Contractor's Name 19 License # iR Ce $e Phone Z&Ce0 S"�- <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN / / RECONDITION /_7 DESTRUCTION /`7 <br /> PUMP-INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT /?- T s <br /> DISTANCE TO NEAREST: SEPTIC TANK ,9 SEWER LINES PIT PRIVY, - <br /> SEWAGE <br /> RIVY -SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE`PIT OTHER <br /> �I <br /> INTENDED USE. TYPE OF WELL _ CONSTRUCTION SPECIFICATIONS - <br /> Industr3al z Cable Tool Dia, of Well Excavation /;Z <br /> _ Domestic/private Drilled Dia. of Well Casing 8•' <br /> Domestic/public Driven Gauge of Casing - Ig <br /> Irrigation , Gravel, Pack Depth of Grout Seal S--d • ._ <br /> Other + Rotary Type of Grout <br /> Other Other Information1 <br /> F <br /> i r <br /> PUMP INSTALLATION: Contractor - <br /> Type of Pump _ H.P. _ <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: J_..--/ State Work--Done <br /> ESTRUCTION OF WELL: Well Diameter ' Approximate Depth <br /> Describe Material and Procedure <br /> F <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 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. i <br /> SIGNED TITLE <br /> (D W PLOT AN ON REVERSE SIDE <br /> i <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTER BY DATE1 <br />` ADDITIONAL COMMENTS: <br /> - - <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY �. DATE Ej INSPECTION BY DATE <br />`_CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M _ <br />