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4 f. <br /> SAN JOAQUIU LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. fiazelton Ave. , Stockton., Calif. <br /> Telephone: ' (209) 4666781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. .7.)�._y E : <br /> HIS PERMIT EXPIRES 1 YEAR'FRONM DATE ISSUED Date Issued 0-. -7a, <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 with San Joaquin <br /> County Ordinance-No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION f �v Rd CENSUS TRACT Sy <br /> Owner's `Name - Phone '2/ _ZA11 <br /> L_,: . <br /> Address / ^� G ��� City <br /> Contractor's Namee Ls <br /> � ye _ License #• /;,gy' Phone <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN ' RECONDITION /_7 DESTRUCTION /_7 � <br /> __ PUMP INSTALLATION ' UMP REPAIR [—/ PUMP REPLACEMENT / <br /> i <br /> r Other <br /> i DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER I <br /> ,INTENDED USE Type -OF WELL CONSTRUCTION SPECIFICATIONS � <br /> d{ Industrial S Cable Tool Dia. of Well Excavation <br /> Domestic/private s Drilled Dia. of Well Casing G <br /> Domestic/public Driven Gauge of Casing + / g <br /> ., -Irrigation Gravel,-Pack Depth of Grout Seal �-- <br /> . Other 3 Rotary.- Type of Grout . <br /> r ! Other Other Information ��„� c�d \Ij Y <br /> _.� <br /> PUMP' INSTALLATION: Contractor ! <br /> Type of Pump H.P. <br /> PUMP -REPLACEMENT: ` / /--,State Work Done <br /> PUMP REPAIR: / / State-WorkDone-,--- <br /> } <br /> ..PESTRUCTION OF WELL: Well. Diameter ,Approximate Depth <br /> Descrikie'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 any 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 /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE ' <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY :L� DATE.' -77— <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 - 4/72 1M <br />