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M f f <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE URE 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.7 - _o3 0 <br /> THIS-PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application imade' to' the San Joaquin Local Health District fora 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 -arid the -Rules and Regula ons of the an' J aquin'Local Health District. <br /> JOB ADDRESS/LOCATION wLl��7 rCENSUS TRACT <br /> Owner's' Name Phone - <br /> Address City <br /> Contractor's Name 1 License # --Phone•' _ A <br /> TYPE OF WORK (Check) : NEW_WELL DEEPEN /7// -REC DITION /_7 DESTRUCTION.. <br /> PUMP INSTALLATION / / PUMP- REPAIR / / PUMP REPLACEMEOT <br /> Other <br /> DISTANCE T& 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 Casing1� <br /> Irrigation" Gravel Pack Depth of Grout Seal J � <br /> Other Rotary Type of Grout <br /> Other Other Information . , <br /> PUMP INSTALLATION". Contractor ` <br /> Type of Pump. H.P. ; <br />` PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR" � State- Work <br /> / / State Work Done <br /> } <br /> ,DESTRUCTION 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 ofnew•we11;WI will-furnish the San Joaquin. Local Health District a N <br /> WELL DRILLERS REPORT of the-well- And notify` them before putting the well in use. The above <br /> information = s t to the be t ofm y no edge and belief. <br /> I SIGNED ® ITLE' ., Q /��/'9 <br /> t <br /> Z.(DW PLOT PLAN 0 RE SE SIDE ` <br /> OR DEPARTMENT USE ONLY <br /> PHASE I _. - -- a <br /> APPLICATION ACCEPTED BY k- DATE -� _ <br /> ADDITIONAL COMMENTS: Z. <br /> PHASE II OU SPEC%0N PHASE III/FINAL INSPECTION <br />+ INSPECTION BY '­DATE '" INSPECTION BY i' ATE <br /> CALL FOR A GROUT .INSP.ECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />