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ter. <br /> SAN n-AQUIS LOCAL HEALTH DISTRICT <br /> FOR OFFICE U5E: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ? <br /> THIS PERMIT EXPIRESy 'YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health` Districtfor a permit to construct <br /> and/or install the work herein described. This application is made incompliance with San Joaquin <br /> Rules and Regulations of the San Joaquin Local Health District. <br /> County Ordinance No. 1862 and the <br /> lF < •`� ccf;-�'Tsf` cENsus TRACT <br /> JOB ADDRESS/LOCATION cr72 : 7 7'1- 64-4 <br /> 4 Phone 447 4G 8'/ <br /> Owner's Name <br /> Address l d Z_co 16' _210/0"21City <br /> Contractor's Name a License # / 3 a� Phone 7415"1 3qy <br /> TYPE OF WORK (Check): NEW WELL I DEEPEN_/!� RECONDITION l_7 DESTRUCTION /`7 <br /> i PUMP INSTLATION PUMP' REPAIR / / PUMP REPLACEMENT /� <br /> AL <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 X <br /> . Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> 7,61 <br /> PUMP INSTALLATION*. Contractor <br /> Type of Pump n H.P. 75 <br /> I <br /> PUMP REPLACEMENT: / / State Work Done <br /> f _ <br /> PUMP REPAIR: / / State Work Done <br /> ESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> t <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 t TITLEi <br /> (DRAW PLO LAN ON REVERSE SIDE <br /> FOAKDEPARTMENT USE ONLY <br /> PHASE I �'' DATE �- <br /> APPLICATION ACCEPTED B7-7 <br /> ADDITIONAL COMMENTS: r <br /> PHASE II GROUT INSPECTION PHASE ;IJAFINAL INSPE ION <br /> INSPECTION BY _ DATE INSPECTION BY DATE <br /> � r <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> 7/72 1M <br /> E H 1426 <br />