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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 2601 E. Hazelton Ave:; -Stockton, Calif. <br /> Telephone: (209) 4666781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.7�� � <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE YSSU.ED" 2' ': 73 <br /> Date..]Issued -�_J3 <br /> (Complete In Triplicate)-­­' Application is hereby made to the San Joaquin Local Health-l)istric.t for a permit to construct <br /> and/or install the work herein described. This application is made' in compliance with San Jaa uit <br /> County Ordinance o. $ nd the Rules and Regulations of the San Joaquin Loca Health District. <br /> JOB SSS/LOCATION Qs? <br /> � �pSU TRACT <br /> Owner's Name <br /> rte <br /> Phone - <br /> Address <br /> - City <br /> Contractor's Name sv <br /> Lcens Phone <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN RECONDITION /_7/_7 DESTRUCTION /_7 <br /> PUMP INSTAfLATION PUMP REPAIR /—/ PUMP REPLACEMENT /-7 <br /> Other /% <br /> r -- <br /> DISTANCE TO. NEAREST: SEPTIC TANK SEWER LINES <br /> SEWAGE, DISPOSAL. FIELD ` PIT PRIVY — <br /> I , , _ CESSPO L/SEEPAGE PIT/Q0 4- OTHER_42,r p <br /> 1NTENDED USE TYPE OF WELL <br /> IndustrialCONSTRUCTION SPECIFICATIONS 1 <br /> Cable Tool Dia, of Well Excavation <br /> Domestic/private Drilled Dia. of Well„Casing ' <br /> Domestic/public Driven - <br /> Irrigation �.,,Qauge_.of:"Casing -� - F <br /> Other Grave Pack Depth of Grout Seal <br /> Rotary Type of Grout <br /> Other Other 'Information <br /> ` I <br /> PUMP INSTALLATION: ' ' <br /> Contractor <br /> Type of Pump . 6 <br /> PUMP REPLACEMENT: <br /> .. State Work Daae. <br /> PUMP REPAIR: <br /> / / State Work Done <br /> ESTRUCTION OF WELL: Well Diameter <br /> Describe-Material and Procedure Approximate Depth <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District r <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 /> SIG f <br /> TITLE !C ` 1`*�_. <br /> ( RA PLOT PLAN ON REVERSE SIDE - <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: - DATE_ <br /> PHASE II GROUT. -INSPECTION <br /> INSPECTION BY <br /> _HA II IN <br /> AL INSPECTIO <br /> 7 <br /> DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECT ON. � <br /> E H 1426 <br /> 7/72 lM <br />