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0 SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 ,L <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued / _02 r,,f <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 /> qJOB ADDRESS/LOCATION <br /> CENSUS TRACT <br /> Owner's name f, Phone <br /> Address . ,L' neon �..._._ _ City <br /> K3 -7570 <br /> Contractor's Name License # Phone a'O"o <br /> TYPE OF WORK (Check): NEW WELL DEEPEN /_7 RECONDITION /7 DESTRUCTION /_7 <br /> PUMP INSTALLATION /—/ PUMP REPAIR /—/ PUMP REPLACEMENT /_ <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY -11 <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER "C <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia, of Well Casing n <br /> Domestic/public Driven Gauge of Casing <br /> _ r Irrigation Gravel Pack Depth of Grout Seal ` <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type.-of Pump - - - g.P.�' ' <br /> w <br /> PUMP REPLACEMENT- / / State Work Donel <br /> PUMP REPAIR: /% State Work Done' <br /> ESTRUCTION OF WELL: Well Diameter <br /> - _ Approximate Depth <br /> Describe Material and-Procedure <br /> e4l <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 1 <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 notifylthem before putting the well in use. The above <br /> information is true to the best 'of- myknowledge and belief. <br /> SIGNED _ <br /> _:; _ ,-......! TITLE <br /> (DRAW PLOT ,PLAN ON REVERSE SIDE <br /> FOR ARTMENT USE ONLY <br /> PHASE I , <br /> APPLICATION ACCEPTED B6� <br /> ! 2446&- T DATE f Z Z <br /> ADDITIONAL COMMENTS: 61 V <br /> PHASE II GROUT INSPECTION!, R PIIJUnNAL INSPECTION <br /> INSPECTION BY DATE INSPECTIQ DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 IM <br />