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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: <br /> 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-67$1 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 <br /> C �lnl <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> In(Complete - <br /> APPlication is hereby made to the SanJoaquin Triplicate) <br /> Local District � <br /> and/or install the work herein described. This application is made inrcompliancetwithnct SanuJoaquin' <br /> County Ordinance No J, 1862 2ad' the Rule - <br /> " � and Regulations of the San Joaquin Local Health District,RRO�7"DdU' <br /> JOB ADDRESS/LOCATION <br /> CENSUS TRACT <br /> Owner's Name <br /> t Phone Y4?. R-2 <br /> Address <br /> City <br /> Contractor's Name �S_S� 6_ <br /> License 11 d»y Phone M X5"24) <br /> TYPE-OF-WORK-(Check) NEW WELL-4_7 DEEPEN- /-/F °RECONDITION 'F�D4STRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other L-1 <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> 6°6 SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT <br /> OTHER <br /> INTENDED USE TYPE OF WELL <br /> Industrial CONS UCTION SPECIFICATIONS <br /> -- � Cable Tool Dia. of Well-Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic '� <br /> /public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> 1 t <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump r <br /> H.P. : <br /> PUMP REPLACEMENT: / / State Work Done - <br /> PUMP REPAIR: /% State Work Done <br /> ESTRUCTION-OF=•WEL-L:=- e-11A-Di-ameter- <br /> Describe Material and Procedure', Approximate'=Depth : <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 /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> kPPLICATION ACCEPTED BY DATE <br /> kDDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION P E, I AL INSPECTION <br /> INSPECTION BY DATE INSPECTI�BBY <br /> DATE Z I-2_F_,�� <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 <br /> _ 7/72 1M 3� <br />