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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. i <br /> Telephone: (209) 466 .6781 ! <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Z-7 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 3_x.2-73 <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 <br /> Health District. <br /> JOB ADDRESS/LOCATION X300 oALbkie R� CENSUS TRACT 2 1 IS. <br /> Owner's Name—t1'- <br /> ----+��-.�"12*53 LOP WE 07 A4-� Phone � 03% <br /> . <br /> zc 3� i <br /> Address FS .. IU "(` . City lzrr-U <br /> Contractor's Name `j License # L&--03 74 <br /> a'Z 7 9G hone <br /> d <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN / / RECONDITION DESTRUCTION /7 <br /> PUMP INSTALLATION /g/ PUMP REPAIR / / PUMP REPLACEMENT /- <br /> Other / / ` <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ,PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE, TYPE OF WELL CONSTRUCTION SPECIFIC IONS <br /> Industrial *1e Cable Tool Dia, of Well Excavation „ <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing. J Q <br /> Irrigation Gravel Pack Depth of Grout Seal p <br />'i <br /> Other Rotary Type of Grout (30fT• d . <br /> Other Other Information �d Stl <br /> a <br /> 1 IJACTAU <br />. PUMP INSTALLATION: Contractor !N v <br /> ft <br /> Type of Pump H.P. r <br /> PUMP REPLACEMENT: w' / / State Work Done `fid d� 1 •� <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 knowled a and elief. <br /> SIGNED VCU 111 v TITLE <br /> (DRAW PLOT ON VERSE SIDE <br /> FOR DEFkRTMENT USE ONLY <br /> PHASE I l ' <br /> APPLICATION ACCEPTED I - � DATE 3W� .� J 7 3 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE j -,27-7-37 INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />