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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. <br /> Z-1 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 2 <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 and0the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESSft"OeATM 600 /VP_044 r I?aa el z CENSUS TRACT <br /> 4� <br /> Owner's NameI/�� t^Q Phone , <br /> Address City <br /> � �//lr�: _ �GaI6 --- - -- - - City <br /> i <br /> Contractor's Dame �_ �.icense & hone /f/ <br /> TYPE OF WORK (Check} : NEW WELL / / DEEP DESTRUCTION <br /> / / RECONDITION /-7f I—T <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /� { <br /> Other / / <br /> i <br /> DISTANCE TO NEAREST: SEPTIC TANKSEWER LINES�" jt PIT PRIVY_yL �ff'fQ <br /> SEWAGE DISPOSAL FIELD - P9AL/SEEPAGE PIT/� OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS � + <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing QE <br /> Irrigation �{ Gravel� Pac_k Depth-of Grout Seal . <br /> Other x Rotary ..Type of Grout cle � <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor Y! <br /> Type of Pump H.P. 7L- <br /> _PUMP REPLACEMENT: / / State Work Done <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 ori 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 tru to the.best of my knowledge and belief. <br /> SIGNED TITLE -- __ <br /> (DRAW P OT PLAN ON REVERSE SID J <br /> F DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED B DATE 7/_p P17 <br /> ADDITIONAL COMMENTS: I 77 7 <br /> PHAS,E II GROUT INSPECTION PHASE III FINAL INSPECT ON " <br /> INSPECTION BY _ DATE Z—, =73 INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />