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tj RV SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE; 1601 E. Hazel tori`Ave:,':Stockton, Calif. <br /> Telephone:'..,,(209) `466--6781 - _.,�t ° <br /> PLICATION FOR WELL CONSTRUCTION PUMP PERMIT Permit No. 7] x-61 <br /> THIS PERMIT•EXPIRES:l=-YEAR'.FROM DATE ISSUED Date Issued . Z - 2, <br /> .r:•,(.Complete 'I'n Triplicate) - <br /> Applicatiorr�,is?hereby.tmade'i.to 'the�)SanIJoaquin� Local.health District for a permit to construct <br /> and/or install the work herein described. Thismapplicati°on, is made in compliance with San Joaquin <br /> County Ordinance,No. 1862./a/rynd,-the-iRule.s,,and,°=Regula-tions-•of w the. Safi Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT { <br /> Owner's'Name: a =b� F ,; ri +$ . '; � i .. Phone <br /> City <br /> Address <br /> i <br /> License # Phone Sy <br /> Contractor's Named' <br /> AP <br /> Z,. <br /> JI <br /> TYPE OF WORK (Check) : NEW WELL/ / (DEEPEN '/ I RECONDITION /_� DESTRUCTION <br /> PUMP INSTALLATION / I PUMP REPAIR PUMP REPLACEMENT /- <br /> Other, / / -- <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES, .i PIT PRIVY <br /> SEWAGE DISPOSAL FIELD `: CESSPOOL/SEEPAGE PIT OTHER <br /> \ <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 _ <br /> Irrigation �.�. Gravel Pack �LDepth of Grout( Seal cv `a <br /> s Other Rotary Type of Grout/ � .M <br /> Other Other Information � € <br /> C <br /> 'UMP INSTALLATION: Contractor + , <br /> Type of Pump ! i777117�3 C4 <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / State Work Done <br /> .DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure 1 <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 'thelSan 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 belie.- <br /> SIGNED <br /> eliefSIGNED TITLE _ <br /> (DRAW PLOT P ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I 3 DATE <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE IIIINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE Z <br /> CALL .FOR A GROUT INSPECTION TO_GROUTING AND .FINAL INSPECTION. 4/72 1M <br /> E H 1426 <br />