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SAN JOAQUIN LOCAL HEALTH DISTRICT ` <br /> FOR OFFI USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7-3 3°p-5--lJ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued. 6_.2-&- <br /> (Complete In Triplicate) "" I <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 q 7 3 <br /> CENSUS TRACT <br /> Owner's Name Phone <br /> Address <br /> City <br /> Contractor's Name C IAZCA< * - ' Q U 7 J?4 G G. License # BGG ._z Phone 4/42-4 4 P7 <br /> . -- - _ 0 <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN <br /> .� _/ / RECONDITION /-7 DESTRUCTION /-7PUMP INSTALLATION / / PUMP REPAIR /—/ PUMP REPLACEMENT /7 <br /> Other /% — — — <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> 1 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS ` <br /> ^� Industrial y_ Cable Tool Dia, of Well Excavation " <br /> Domestic/privateff <br /> I Drilled <br /> _ Domestic/public D3-a, of Well Casing �I <br /> Driven Gauge of Casing W <br /> Irrigation Gravel Pack Depth of Grout Seal ,gyp <br /> Other Rotary Type of Grout ,( Y <br /> Other Other Information �— <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: F ' <br /> / ,/ State Work Done <br /> PUMP REPAIR: / / State Work Done <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 I <br /> information is true to the best of my knowledge and belief. <br /> s <br /> SIGNED TITLE G <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY --4DATE -75 <br /> /7 V7 <br /> ADDITIONAL COMMENTS: 3 <br /> PHASE II GROUT INSPEtTION PHASE III FINAL INSPECTIO j <br /> INSPECTION BY DATE INSPECTION2 -3 <br /> BY DATE �� <br /> a..�C ON/ NG' 1I�T� <br /> CALL FOR A GRO T INSPECTION P R TO RO I D FINAL INSPEC ON. <br /> H 1426 _ 7/72 1M <br />