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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton'Mre.-:,�­'Stockton, Calif. <br /> Telephone --(2'09)-..T;466' 6781 <br /> :FAPPLICAT ION FOR WELL CONS I TRUCTIOR{OR PUMP PERMIT Permit No. F7,7- 9 51 <br /> - <br /> THIS PERMIT. -EXPLRE&,!-11':XfEAXFROM;DATE.s 1,SSUE-D; - Date:,Issued <br /> '1, <br /> Applicati,oW,j-.i ..,!horeby-f,mad,e'tt,o Ithdl!S'a:n.7,,JO.a:qtii.n:°Zooa1 H&al7th District=. f-or.�a--.pe'r'init-,tb ,,construc:t <br /> iance with­San'-�Joaquin <br /> and/or install the work herein described:' T;hig�-.�ap�yliieati-on,� i's�';ma�de",in.,-icomp.l 'District. <br /> County -ina'nc:e--P�No-,-.il`862,�i-a,nd-,�,-th'e'-;s,R,u-1eitEand�-,9Regllla,t,i-.ons,.,btLl;the San' ',Joaquin'Local: He�alth <br /> _4� <br /> JOB ADDRESS/LOCATION 1.4Lw"- CENSUS-TRACT <br /> af, <br /> N <br /> u <br /> Ow-ner!.soN <br /> Address City <br /> Contractor's Name License # Phone ' <br /> TYPE OF WORK (Check) NEW WELL /,Of DEEPEN I I RECONDITION DESTRUCTION /_7 <br /> PUMP INSTALLATION /_;7f_'PUMP REPAIR REPLACEMENT <br /> Other: <br /> . DISTANCE TO NEAREST: 'SEPTIC TANK' `LSEWER LINES - <br /> 3 PIT PRIVY V3 <br /> EWAGE DISPOSAL FIELD, . CESSPOOL/SEEPAGE Pit. OTHER <br /> \in <br /> INTENDED USE .... TYPE' OF WELL. CONSTRUCTION SPECIFICATIONS <br /> Dia.Cable .Tool LO <br /> .1ndustria <br /> Domestic/private. Drilled Dia. of Well Casing 6& <br /> Domestic/public Driven' :' Gaugd,ofCasing 1'7- <br /> irrigation Gravel,Pack. -Depth of, Grout Seal 5_0 <br /> Other Rotary Type :of ;Grout <br /> Other Other Information' <br /> PUMPmINSTALLATIONi ' Contractor n tv_npr <br /> Type of Pump wpss I btf— H.P. [4p <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 <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 /> aft r completiori of 'my work on a new well, I will furnish the San Joaquin Local Health Distridt 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 be' st. ofmmy-kno'wledge and b:elief.'m <br /> SIGNED TITLE <br /> y (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Of <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> DD TIONAL CONI <br /> PHASE II ,GROUT INSPECT ON PHASE ,KI/FINAL INSPECTION <br /> INSPECTION By PATE INSPECTION DATE <br /> i <br /> CALL FOR A GROUT INSPECTION PKO-R TO GROUTING AND FINAL INSPeT;PN. __,__ <br /> E.1 H M.142,6 4/72 1M <br />