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Z <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (20.2�) 466-6781 ' <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit Not / <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED . . Date Issued <br /> Z$3 G . may C om' Gn� (Complete In Triplicate)' O�13 --(70--0 7 <br /> Application is hereby made tolthe San Joaquin Local Health District. for a permit, to construct <br /> and/or install the work herein described. This application is made incompliance with,San Joaquin <br /> County Ordinance No. 2862 and;the Rules and Regulations of -the San Joaquin Local .Health District. <br /> 7,7 h x r r <br /> JOB ADDRESS/LOCATION j d A SAA c - T E.S F of SNi wd..; CENSUS TRACT `7S6 � � { <br /> ' -,E1R IVC & r bFyaJ?wcy4A <br /> Owner's Name -Phone <br /> Address City C i 1e/V <br /> Contractor'a Name R1 15R0,95 _._ License Phone749�SlaS <br /> TYPE OF WORK (Check) : NEW WELL /5�' DEEPEN /? RECONDITION /__7 xDESTRUCTION /_7-- ` <br /> Nib <br /> PUMP INSTALLATION REPAIR PUMP REPLACEMENT /_7 <br /> Other /_7 ; <br /> t <br /> DISTANCE TO NEAREST: SEPTIC TANK :0, SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER Z <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrialx_ _ Cable Tool . Dia, of Well Excavation /.2" I� - <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public V Driven -- Gauge of Casing 12- <br /> Irrigation <br /> ZIrrigation Gravel Pack Depth of Grout Seal y'o ` <br /> Other I Rotary Type of Grout <br /> 3 Other Other Informations <br /> r <br /> PUMP INSTALLATION: Contractor <br /> Type ofPump �C H.P. t <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP-REPAIR-:-, <br /> - State Work Done <br /> kUTRUCTION OF WELL: Well Diameter ! Approximate Depth j <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 /> i <br /> SIGNED TITLE j <br /> (DRAW PL PLAN ON REVERSE SIDE } <br /> " FOR DEPARTMENT USE ONLY <br /> PHASE I �� r � � ... <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: _ _ 7 I <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> 7CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 �y 7/72 1M <br />