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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 3601 E. Hazelton Ave. ,= Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit Na. ZZ- 5 -1S <br /> V <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 6 /b Z <br /> (Complete -In `Triplicate) <br /> Application isrhereby� made to the San .7oaquin- 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 ules and -Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATIO'N :90-7 D CENSUS TRACT <br /> Owner's Name��- l/ c- l�j� Phone <br /> Address G -�" G 4�2La2'� City �4L <br /> Contractor's Name License #c -&"44?T/Phone <br /> TYPE OF WORK (Check) : NEW WELL/ DEEPEN /_J RECONDITION /-7 DESTRUCTION /- x <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT /— <br /> d <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 <br /> CONSTRUCTION SPECIFICATIONS O <br /> Industrial Cable Tool Dia. of Well Excavation <br /> 4,--Domestic/private. Drilled Dia. of Well Casing 0 <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary *1 Type of Grout <br /> Other Other Information d <br /> PUMP INSTALLATION: Contractor T. Z& f <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> DESTRUCTION <br /> 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 /> information i ue the best of my knowledge and belief. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) _ <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHA III/ IN INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE -- <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 4/72 1 <br />