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SAN�JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE:" 1601 E. Hazelton- Ave ,-'Stockton, Calif. <br /> Telephone: ' (209) 466- 6781 �1 <br /> APPLICATION FOR WELL CONSTRUCTION �OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES`-1 YEAR FROM DATE ISSUED Date" Issued �73 <br /> (Complete -In Triplicate) <br /> Application%is=tierebyymade to� the San Joaquin 'Local Health District for a'permi'f to"construct <br /> and/or install the work herein described. • This- a lication is made in com 1'iance'w <br /> pp p i.th San Joaquin <br /> County Ordinance .-No. 1862 and the Rules arid Regul tions of the Sati Joaquin Local Health District <br /> -400,S. <br /> gq . ' <br /> JOB ADDRESS/LOCATION ��-- ENSUSTRACT <br /> Owner's Name Phone 'o <br /> C t <br /> Address K _r. - City. <br /> Contractor's Name License License # Phone • �3 / <br /> TYPE OF WORK (Check) : NEW WELL / f DEEPEN /_7 RECONDITION' <br /> _ _/_7 DESTRUCTION /? <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /- <br /> Other /_7 <br /> DISTANCE TO <br /> 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 C <br /> Irrigation . .Gravel Pack Depth of Grout Seal j <br /> Other Rotary Type of Grout „ . <br /> Other Other Information <br /> r PUMP INSTALLATION: Contractor C lZ_9 <br /> ��OcIW <br /> Type of Pump H.P. <br /> i <br /> i PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR* / / State Work Done <br />� ESTRUCTION OF WELL: Well Diameter '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 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 SW140 TITLE - <br /> (DRAW OT 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 26n ,r=, DATE -- _ <br /> CALL FOR A..GROUT INSPECTION,PRIOR.TO. GROUTING AND -FINAL INSPECTION. QD <br /> E H 1426 7/72 1M <br />