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SAN JOAQUIN LOCAL .HEALTH DISTRICT <br /> FOR OFFICEUSE: 1601 E. Hazelton•Ave. ,' Stockton Calif. <br /> q �� Telephone : (209)' 466-6781 <br /> a <br /> APPLICATION FOR WELL. CONSTRUCTION OR PUMP PERMIT Permit No. 7z_- <br /> ?f,�f <br /> THIS PERMIT"EXPIRESr"'1 YEAR FROM DATE ISSUED Date Issu, <br /> -(Complete, In Triplicate) r <br /> Application isatie by'madeito the3San'Joaquin'Local Health District for a permiti'to construct <br /> ,.and/or install the work herein described. This 'ap,plication is made in*complance:with San Joaqui <br /> }' County OrdfnanceNo. ,1862,.`and,:the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB :ADDRESSAOCATION A., 2�5'�a?fl Yr <br /> CENSUS TRACT' <br /> . Owner's Name <br /> Phone <br /> - Q9 Q 7 <br /> J; AddressIQ 41v- <br /> Contractor�.s..Nam <br /> License # g�C <br /> l -7;2 Phone gag 7S',>6 <br /> i=TYPE•OF WORK (Check): NEW WELL. ./ DEEPEN / / RECONDITION /? DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR L/ PUMP REPLACEMENT /_7 <br /> k Other /% — <br /> a <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES Lop . PIT PRIVY <br /> y <br /> w. <br /> SEWAGE rDISPOSAL FIELD CESSPOOL/SEEPAGE PIT` OTHER S <br /> � INTENDED USE <br /> Y <br /> TYPE. OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> x Domestic/private Drilled Dia. of Weil 'Casing , r <br /> Domestic/public Driven <br /> Gauge of Casing _ I�9u krc,• �A�� <br /> Irrigation Gravel Pack- Seal- <br /> Other <br /> —e--- <br /> ••— � Depth of Grout Seal .� <br /> Other <br /> Rotary <br /> y Type of Grout _ R�� b�rrra <br /> Other % Other Information . <br /> PUMP INSTALLATION: _ - -- <br /> Contractor: <br /> - <br /> -Type-of -Pump <br /> H.P. <br /> ,PUMP REPLACEMENT: / / . State Work Done <br /> ; PUMP REPAIR. / / State Work Done <br /> j,)ESTRUCTION OF WELL: Well Diameter <br /> - - tAPProximate Depth '' <br /> Describe__Material_and_ Procedure_':_­::-"'�""�"a. _ - -- <br /> I hereby:agree to comply with all laws and -regulations of the A an -Joaquin 'Local Health District <br /> rand 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 . <br /> r TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLX <br /> i7PHASE I <br /> 'APPLICATION ACCEPTED BY i <br /> ;ADDITIONAL COMMENTS: DATE . ' <br /> k. <br /> P SE II GROUT INSPECT .. N P E I I F NAL INSPECT <br /> INSPECTION BY ` DATE INSPECTION BY DATE <br /> r <br /> CALL FOR A GROUT INSPECTION-PRIOR':;TO GROUTING AND FINAL, INSPECTION: <br /> E H 1426 <br /> 7/72 1M (��' <br />