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1' <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave.',' 'Stockton, Calif. <br /> Telephdne: (209) 466-6781 <br /> APPLICATION FOR WELL-CONSTRUCTION OR PUMP PERMIT Permit No. 7 <br /> THIS`PERMIT EXPIRES '1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is-hereby`-made-to;-the San Joaquin Local Health Di'stric't 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-.t'1-862f and the 'Rules 'arid' Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION . .3� C� �/`/c� _IDS CENSbS TRACT S114 <br /> Owner*sy-Name .l�'� / "adz z tlPhone`" <br /> Addressz6 City. 1d /�_ <br /> Contractor's Name (V XJelcl—l - License # Phone <br /> 1 <br /> TYPE OF WORK (Check) : NEW WELL /_7 DEEPEN & RECONDITION /_7 DESTRUCTION /_ <br /> PUMP INSTALLATION 4KI PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other /_7 <br /> DISTANCE TO 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 Cabl Tool Dia. of Well Excavation <br /> T Domestic/private�ed Dia, of Well Casing _ �� " <br /> CIV <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout M <br /> Other Other Information ` <br /> a <br /> PUMP INSTALLATION:— Contractor to&1:v <br /> Type of Pump H.P. / <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 /> 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 DFS ARTMENT 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 &::;2 <br /> CALL FOR A GROUT .INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />