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r /0 s1z� <br />- SAN JOAQUIN LOCAL BEALTH DISTRICT <br /> FOR OFFICE USE: ' 1601 E. Hazelton Ave. , Stockton, Calif. ! <br /> Telephone: (209) 466-6751 <br /> PLICATION FOR WELL CONSTRUCTION-.OR PUMP PERMIT Permit No. JZ--]7 0 <br /> THIS PERMIT EXPIRES. 1 YEAR FROM DATE'ISSUED- Date Issued 7.7 7.7 v <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 /> z-rn I� Is <br /> JOB ADDRESS/LOCATIONeo DG fJ ,G`' 7-A? It- iZ CENSUS TRACT <br /> Owner's Name .r y-t Phone 4/- 4,1. 6 0 <br /> Address f-- AfA/A/ _ City �--€ <br /> Contractor's Name actlf. License # 4s-,a 4(Phone '7 ziS'i0 4-�L <br /> TYPE OF WORK (Check) : NEW WELL /X DEEPEN '/ / RECONDITION l�T DESTRUCTION <br /> PUMP INSTALLATION/ / PUMP REPAIR/ / PUMP REPLACEMENT <br /> Other /—/ — <br /> DISTANCE TO NEAREST: SEPTIC TANK 7 p s SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial X Cable Tool Dia. of Well Excavation ' <br /> _ <br /> Domestic/private Drilled' Dia. of Well Casing ig <br /> Domestic/public Driven Gauge of Casing l s <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout ;01 <br /> Other Other Information ' <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump SGy13 - 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 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 �..�✓ Q f � TITLE <br /> (DRAW PLO PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY _ _ DATE ;-;PZ-2 7 <br /> ADDITIONAL COMMENTS: <br /> PHA E I GROUT INSPECTION JPSE I/FINAL INSPECTION <br /> INSPECTION BY DATE S- INSPECTION BDATE CALL FOR A OUT INSPECTION PRIOR TO GROUTING ANDFINAL INSION. <br /> t E H 1426 4/72 1M /�, <br />