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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> OI <br /> F F. IICr, USE.. 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 6i-__5i <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued Z-g-7 <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. 1562 and the Rules and Regulations of the San Joaquin Local Health Dis;riot. <br /> JOB ADDRESS/LOCATION (� S.r/e0/V A n H&,,J CENSUS TRACT <br /> Owner's Name Z'o C&,Fi d / Phone e16 y L7 <br /> Address /Zai E �//I/� . ..._ . —.. City S'7'/C M C-A,-/,A- <br /> Contractor's Name License 4E�6S74Phone q&cr <br /> TYPE OF WORK (Check): NEW WELL /_7 DEEPEN '/—/ RECONDITION /_/ DESTRUCTION /_7 <br /> PUMP INSTALLATION /% PUMP REPAIR / J 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 SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing V. <br /> 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 .2 <br /> PUMP <br /> PUMP REPLACEMENT• State Work Done <br /> PUMP 'tEPAIR: / J State Work Done <br /> .DFGTRUCTION 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. D <br /> SIGNEDt �ITLE �-■-�c�- <br /> (DRAW-PLOTPPLAN ON REVERSE SID <br /> 'FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY c DATE ` 17 74- <br /> ADDITIONAL COMY1ENTS: <br /> PHASE II GROUT INS CTION PHAS , I.IlIZINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY ff '. + DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> y E H 1426 5/731M <br />