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FOR OFFICE USE: f SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. Hazelton Ave: , Stockton, Calif. <br /> s Telephone: (209) 466-6781 <br /> PLICATION FOR WELL CONSTRUCTION Ok PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED , <br /> Date Issued <br /> (Complete In Triplicate) I?y 71 Y <br /> �. y made -'to the San Joaquiri•Local Health District for a'permit to construct?v <br /> Application is hereby <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 /> i JOB ADDRESS/LOCATION , <br /> CENSUS TRACT <br /> fOwner's 'Name <br /> Phone ' <br /> 4 Address <br /> City I.:-�eD>f' <br /> Contractor's Name - 1p License # <br /> Phone <br /> • .-.-_ -.. .mo�w}}--J..-. <br /> TYPE OF .WORK (Check) .' NEW, WELL/ '-DEEPEN -/ / RECONDITION '/_� DESTRUCTION <br /> 'PUMP INSTALLATION�� PUMP REPAIR / / PUMP REPLACEMENT /-7 ;I <br /> ---. <br /> DISTANCE`TO NEAREST: SEPTIC• TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELDCESSPOOL/SEEPAGE'-PIT OTHER <br /> INTENDED USE <br /> TYPE OF WELL <br /> IndusCONSTRUCTION SPECIFICATIONS <br /> trial' °. L__—Cable Tool. Dia. of Well Excavation . <br /> Domestic/private Drilled <br /> Dia. of Well Casing Ell <br /> Domestic/public Driven Gauge of Casing I <br /> Irrigation Gravel Pack <br /> Depth of Grout Seal.—/-W 5 H <br /> Other Rotary <br /> y Type of Grout <br /> . ±� Other Other Information ' <br /> - E <br /> F <br /> PUMP INSTALLATION: Contra <br /> ctors /L�i/1/C <br /> Type of Pump. H.P. <br /> i - <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: ' <br /> / / State Work Done <br /> ESTRUCTION OF WELL: Well Diameter t <br /> 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 compl.etion: 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. Th <br /> informatia is true to the best of my knowledge and belief. e above <br /> SIGNED TITLE O � <br /> (DRAW PLOT PLAN ON REVERSE SIDE ,- <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY i <br /> APPLICATION_ ACCEPTED BX_ DATESor <br /> '� <br /> ADDITIONAL COMMENTSs- <br /> - _ PHASE-11- GROUT--INSPECTION - �- - _-- --- -_-- _- PHASE III FINAL NSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSP 1 <br /> E H 1426 <br /> 4/72 1M <br />