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Zr <br /> / SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: l� I601 E. Hazelton Ave:, Stockton, Calif. <br /> a Telephone: '(209)' 466'-6781 <br /> APPLICATION FOR.WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 Z-/O z U <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued g"/Z-7-z- <br /> - (Complete In Triplicate) <br /> Application-.1s hereby-made t. 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 }� �` � _ � � � CENSUS TRACT' <br /> Owner's Name ZJZAA Ph one '- <br /> Z— <br /> Address <br /> �.�_ ,r-P, - f1 - r3'(�, C_ City <br /> Contractor's Name License #/ .l Phone g13,cfg j <br /> TYPE OF WORK (Check): NEW WELL / DEEPEN '/_/ RECONDITION /_/ DESTRUCTION /_ <br /> AL <br /> PUMP INSTLATION/ / PUMP REPAIR/—/ PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES '; PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> i <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation 0i <br /> _��Domestic/private Drilled Dia. of Well' Casing <br /> Domestic/public Driven GaugdFof Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other 4--Rotary ; Type of Grout ' . <br /> Other .k• Other Information <br /> PUMP INSTALLATION: Contractor �. <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> J <br /> - v i <br /> PUMP REPAIR: / / State Work Done <br /> DESTRUCTION 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 is true to the best of my knowledge and belief. <br /> SIGNED L TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR WARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: - <br /> PHASE II GROUT INSPECTION PHAS III./FINAL INSPECTION <br /> INSPECTION BY-- DATE S- -��- INSTI BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E-H 1426 �,.�i 7 4/72 1M <br />