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SAN JOAQUIN LOCAL HEALTH 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 LLI_00 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -/ -72L � <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 /> JOB ADDRESS/LOCATION J 9D �(�� _ y� _- CENSUS TRACT ' <br /> Owner's Name C 1�� Phone ZL,Z �Q <br /> Address, Illi " City <br /> Contractor's Name ��� om License .# Phone <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN /_7 RECONDITION /X DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /_7 i <br /> Other / / <br /> M <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 X_ 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 /> PUMP INSTALLATION: Contractor ' <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: State Work Done l n5-, 4za' 11!1_�C <br /> ESTRUCTION 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 DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> l information is''`true to the t of my knowledge and belief. <br /> I SIGNED TITLE 06-u-?,7 & r <br /> W PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> 1 APPLICATION ACCEPTED BY /06011� DATE / Z <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE IIL/F NAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY - DATE <br /> CALL FOR A. GROUT INSPECTION. PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />