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tl(2 <br /> / SAN .�OAQUTN LOCAL HEALTH DISTRICT <br /> FOR`OFFICE USE: V7 1601 E. Hazelton Ave. <br /> Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Kermit No. 7925-4-41 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued *4-27 <br /> 0 1D X76-f %_ _DFA0, A `. (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health Distr ct for a permit to construct <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 /> JOB ADDRESS/LOCATION y a CENSUS TRACT <br /> Owner's Name Phone ' ' <br /> Address City <br /> Contractor's Name F _3 f� <br /> License # jgo2a Phone <br /> TYPE OF WORK (Check) : NEW WELL Pel DEEPEN /_% RECONDITION /_` DESTRUCTION /_7PUMP INSTALLATION /—/ PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> OtherL// t" <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER,LTNES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER + <br /> INTENDED USE TYPE OF WELL 1 � 4 <br /> - CONSTRUCTION SPECIFICATIONS <br /> Industrial Y, Cable. Tool Dia. of Well Excavation " <br /> Domestic/private Drilled Dia. of Well Casing tj•i � (t1 <br /> Domestic/public Driven Gauge of Casing + � <br /> X -Irrigation '. Gravel Pack Depth of Grout Seal $a, <br /> Other F - <br /> Rotary Type of Grout �;•,� C� s � <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor" <br /> Type of Pump H.P. ': <br /> PUMP REPLACEMENT: /. / State Work Done <br />-PUMP-REPAIR: i <br /> State Work -DoneT� _ <br /> - <br /> ,RESTRUCTION 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 TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE T <br /> APPLTCATION ACCEPTED BY „PATE 5-�.,�-�-�2✓ <br /> ADDITIONAL COMMENTS: , a <br /> PHASE II GROUT INSPECTION PHASE IIIIFIIJAL INSPECTION <br /> INSPECTION BY 1i DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECT ON. <br /> E H 1426 9 P 7/72 1M <br />