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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton 'Ave.,` Stockton, Calif. <br /> ; Telephone.:. {209) 4666781' <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ] Z-.-7 <br /> r. <br /> phi � THIS PERMIT EXPIRES-.1 ;YEAR-FROM DATE ISSUED Date Issued -7. Z 7-7 <br /> .v" (Complete In Triplicate) .`f2- 3D-33 <br /> Application is :hereby:made•ito the-San..Joaqu n"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 Rule s,and Regulations 'of 'the ,San Joaquin Local Health District. <br /> V1-7 <br /> JOB ADDRESS/LOCATION t c CENSUS TRACT -.cy - <br /> Owner'.s:.Name € ;: �r• r�, Phone3c� . . <br /> Address - City. <br /> Contractor's Name License #2.C4 D7tL Phone <br /> i <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN/ / RECONDITION DESTRUCTION /_7 1 <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT /? <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC,TANK SEWER LINES PIT PRIVY -- - - ti <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER 4 <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 j 4R <br /> Irrigation., .. Gravel..Pack,p.-Dep_th--of--Grout-Seal e 2192 <br /> Other. Rotary Type of Grout <br /> i Other Other Information ' -- <br /> a <br /> PUMP INSTALLATION: Contractor <br /> Type of 'PU'mp H.P. <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� I hereby agree to comply with all .laws and regulations of the San Joaquin Local Health District <br /> I 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 r TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I _ <br /> APPLICATION ACCEPTED BY DATE119 <br /> ADDITIONAL COMMENTS: <br /> PHAS II GROUT INSPECTION P S II/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE G• 3--1 <br /> XCALL FOR A GROUT -INSPECTION. PRIOR„TO_GROUTING AND FINAL INSPECT .ON, <br /> j E H 1426 4/72 114 <br /> C C�' <br />