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SAN JOAQUIN LOCAL i'.EALTH DISTRICT <br /> ,OROFFICE USE: 1601 E. Hazelton Ave. , .Stockton, Calif. <br /> / Telephone: . '(209). 466-.6781 <br /> APPLICATION FOR WELL CONSTRUCTION' OR PUMP PERMIT Permit No. 7,? / 'OW <br /> THIS PERMIT EXPIRES 1 YEAIt FRQM-DATE ISSUED Date Issued7 - 7 <br /> /Q 7 <br /> (Complete In Triplicate.) ., - <br /> Application- is <br /> r plicate.) :,Application- is hereby made=.tip the San,Joaquin Local Health District for --apermit to construct <br /> and/or install the work herein described. This° application .is made jn compliance with San Joaquin <br /> r <br /> County Ordinance:No j862�-and- the- Rules .and,?,e.gulations sof-'the'. .San Joaquin Local Health District. <br /> ; South aid®..of W oiib idge Rc feast of Buck Rd. to east end 'of raw of walnut <br /> JOB ADDRESS/LOCATION trees rai• south. CENSUS TRACT S 4 7 <br /> Owner.'8 .Name',i„ .r G <br /> , eorge..Aalange, •Phone ' <br /> ,Address 2033 Queen's Lane City San l► <br /> i Contractor's Name San Joaquin Pump Company, Inc* License # 271800 Phone 369-8171 <br /> .TYPE OF WORK (Check)-: NEW WELL DEEPEN j�/ ECOND 'T10N�%/_` DESTRUCTION-/ -�=-� <br /> PUMP INSTALLATION I / PUMP REPAIR '/—/ PUMP REPLACEMENT /_7 <br /> Other, <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 �_ Cable Tool Dia. of Well Excavation 80 N <br /> Domestic/private Drilled Dia. of Well. Casing 8" �^ <br /> Domestic/public' J Driven Gauge of Casing C• <br /> Irrigation 1 Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of. Grout <br /> " Other Other Inforination <br /> .PUMP INSTALLATION: Contractor <br /> Type 'of Pump H.P. <br /> PUMP REPLACEMENT: / / :State Work Done <br /> PUMP REPAIR: / / State Work Dane - <br /> DESTRUCTION OF WELL: Well :Diameter Approximate Depth <br /> Describe Material and Procedure x <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"j oaquin 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 :frue to the best of my knowledge and belief. <br /> �oe <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE S <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE�'b <br /> ,ADDITIONAL COMMENTS: t <br /> PHASE II GROUTIINSPECTION PHASE FINAL INSPECTION <br /> INSPECTION BY kDATE INSPECTION BY a DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 _ _ 4/72 1M <br />