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SAN JOAQUIN LOtA!711:�-ALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton-Ave. , Stockton, Calif. <br /> Telephone: - (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 Z-7 a-o <br /> THIS PERMIT EXPIRES- 1 YEAR FROM DATE 'ISSUED Date Issued �- I 3 7 Z <br /> I '- (Complete In Triplicate) <br /> t Application is hereby madeito 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 <br /> CENSUS TRACT <br /> IAI r <br /> Owner's Name. - Phone <br /> Address O/- _ <br /> _._. City S <br /> ' Contractor's Name <br /> . License # 'hone ' 5, »Za .sir <br /> TYPE OF WORK (Check) : NEW WELL LV DEEPEN ' _ <br /> _/ j RECONDITION /_7 DESTRUCTION /-7PUMP,jINSTALLATION / / PUMP REPAIR '/—/ PUMP REPLACEMENT /- <br /> Othe'r / / - <br /> DISTANCE TO NEAREST: SEPTIC TANK "'— SEWER LINES PIT PRIVY Y <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 I Drilled Dia. of Well Casing _ N <br /> Domestic/public f Driven Gauge of Casing O. <br /> .Irrigation Gravel Pack Depth of Grout Seal S`a � <br /> Other I X Rotary Type of Grout <br /> Other Other Information " Z. <br /> PUMP INSTALLATION: Contractor a # 24S-7ef <br /> t Type 1f Pump " <br /> H.P. • <br /> PUMP REPLACEMENT: /-7- State Work Done ... <br /> h <br /> E PUMP REPAIR: / / State Work Done <br /> e <br /> .DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure . . . . <br /> d <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 /> SIGNEDLTLE <br /> D PLOT AN ON REVERSE SIDE) <br /> PHASE I i F FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INPHASE IIIjXINAL TNSPEC ION <br /> INSPECTION BY. DATE INSPECTION BY TE g � J <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 ' <br /> 4/72 1M <br />