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SAN JOAQUIN LOCAL, HEALTH DISTRICTx <br /> FO` OFFICE USE: 1601 E. Razelton'Ave. , Stockton, Calif. y, <br /> Telephones -'(209) 4664781 <br /> APPLICATION FOR WELL 4CONSTRUCTION OR PUMP .PERMIT Pexmit No. 7.1--/.Z7-_ <br /> r Date¢ la issued /i <br /> THIS PERMI°T -EXPIRES '1•YEAR FROM DATE `ISSUED <br /> -L- <br /> `.(Complete In Triplicate)._. <br /> de"°to the, Joaquin.Lor Health'District, for a periiit to construct <br /> ui <br /> Application is hereby ma p p; <br /> and/or install the' work herein described. This a plication' is made in.,compliance fai q <br /> County Ordinance No.' 1862 and the Rules- an �io s of the San Joaquin Loca'1 Health,District. I <br /> �. � CENSUS TRACT j <br /> JOB ADDRESS/LOCATION <br /> Phone' <br /> � . -- 3 <br /> Owner's Name <br /> City <br /> Address <br /> License # Phone <br /> Contractor's Name <br /> IYeck)`. NEW WELL / DEEPEN /_/ /RECONDITION / DESTRUCTION /_7TYPE OF WORK (ChPUMP INSTALLATION / / PUMP REPAIR./ I PUMP REPLACEMENT /7 <br /> Other <br /> e; <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER LINES PIT ,PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER �. <br /> CONSTRUCTION SPECIFICATIONS <br /> _ INTENDED USE TYPE OF WEL . 6" <br /> Industrial k-- Cable 'Tool Dia. of Well Excavation <br /> Dia. of Well Casing <br /> Domestic/private Drilled <br /> --�-~- <br /> Domestic/public Driven } Gauge of Casing <br /> Irrigation <br /> Gravel Pack Depth of Grout Seal <br /> --- - Rotary Type r of Grout <br /> Other <br /> Other Other 'Information <br /> � - <br /> PUMP INSTALLATION: Contractor H.P. <br /> Type of Pump <br /> y. <br /> a State Work.Done <br /> 4 PUMP REPLACEMENT: I I < <\I -ro 6RaR Pau1-- <br /> Stateor <br /> Wk Done <br /> PUMP REPAIR-- <br /> Approximate Depth <br /> iiESTRUCTION'OF WELL: Well Diameter <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 completioq 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 /> f . . TITLE <br /> r:`SIGNED <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> i, FOR DEPARTMENT USE ONLY <br /> u RASE I DATE . r �- <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: ' P I INAL INSPECTION r <br /> - PHASE II GROUT INSPECTION j. DATE <br /> "INSPECTION BY DATE INS <br /> CALL FOR A GROUT INSPECTION .PRIOR TO GROUTING -AND FINAL INSPECTION. <br /> 7/72 IM <br /> ti E H 1426 <br />