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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE ,USE: 1601 E. Hazelton Ave. ; Stockton, Calif. <br /> Telephone: _-,(20�.) 466-6781 '12- _ •--r �7 <br /> LIGATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7Z- 1`T P <br /> THIS PERMIT EXPIRES ,1 YEAR FROM DATE ISSUED Date Issued -7Z <br /> j (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 pules. and Regulations of -the San- Joaquin Local. Health District. <br /> JOB ADDRESS/LOCATION , CENSUS TRACT" <br /> Owner's�Name-12 tH, ' a Phone 7 7-7! <br /> AddressCity <br /> Contractor's Name License 4��Phone y /yet <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN/ / RECONDITION / / DESTRUCTION /_ <br /> PUMP INS LATION PUMP REPAIR PUMP REPLACEMENT f? <br /> Other77- <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 loo <br /> V Domestic/private Drilled Dia. of Well Casing n <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Giout Seal <br /> Other —V Rotary Type of Grout <br /> Other Other Information ' <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> PUMP REPLACEMENT: / / State Work Dote <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 TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY uv DATE �1 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION - PHASE FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY ATE ' / Z-- <br /> CALL FOR A GROUT INSPE ION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 4/72 1M <br /> __ �- Z, <br />