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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE:. 1601 E. Hazelton Ave. , Stockton, Calif. <br /> r <br /> Telephone: (209) 466 -6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PU P PERMIT Permit No. 7) -Z" <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION -N4 /5/ ,� ��r^s��r- D� ��.c- CENSUS TRACT 2p/-_D2�E?. 03 '1 <br /> Gt t (a a�' � �+ 9 t *AV— 94P ;E7 7a 76f e, _ i <br /> Owner's Name - -� -,_ _ /r rel -- - Phone <br /> Address /SD !? 1 .rd D .fie City �' f <br /> Contractor's Name d �� s._ License # /�j?;j -Phone 2-^, 6,7-4 <br /> i <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN /_7 RECONDITION /_7 DESTRUCTION /_ j <br /> i <br /> PUMP INSTALLATION / / PUMP REPAIR 1 PUMP REPLACEMENT /? <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES PIT PRIVY W <br /> SEWAGE DISPOSAL FIELD CESSPOOL/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 �4 <br /> Domestic/public Driven Gauge of Casing - <br /> Irrigation Gravel. Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other 'Other Information <br /> PUMP-INSTALLATIONa Contractor <br /> Type of Pump Ae, H.P. / <br /> PUMP REPLACEMENT- state Work Done 01,Y <br /> PUMP REPAIR: / / State Work Done <br /> ,PESTRUCTION 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--a d belief. <br /> SIGNEDTLE �. <br /> ` ( W P PLAN ONaRSIE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> yADDITIONAL COMMENTS: <br /> P II GROUT INSPECTION PHAS I FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE -4-- <br /> CALL <br /> Z/CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M (',63 <br />