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SAN JOAQUINiLOCALHEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelto�n 'Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> ` APPLICATION FOR WELLM CONSTRUCTION OR PUMP PERMIT Permit No. 7.) <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued,7 6 0- '�-- <br /> (Complete In Triplicate) DSS' - 31,0-07 <br /> Application is hereby made to the San Joaquin Locall'. Health District 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. 1862 and the Rules and Ra ulat' of,, th San J in Local Health District. <br /> ; JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name Phone <br /> ' Address 3 City <br /> Contractor's Name r License Phone <br /> TYPE OF WORK (Check) : NEW WELL '/—/ DEEPEN / / RECONDITION _/ DESTRUCTION /-7 <br /> 4 PUMP INSTALLATION 1-7 PUMP REPAIR hi PUMP REPLACEMENT /? <br /> Other / / 711 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD' CESSPOOL/SEEPAGE PIT OTHER <br /> NTENDED USE TYPE OF' WELL 11 CONSTRUCTION SPECIFICATIONS <br /> ndustrial kff( Cable Tool Dia. of Well Excavation <br /> mestic/private r Drilled j Dia, of Well Casing l <br /> Domestic/p lic Driven I Gauge of Casing a <br /> Irrigatio Gravel Pack Depth of Grout Seal <br /> Other Rotary Type' of Grout <br /> Other �. Other Information t <br /> PUMP INSTALLATION: Contractor M <br /> k Type of Pump !M: H.P. i <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: 07 State Work Done- o/ <br /> DESTRUCTION OF WELL: Well Diameter Approximate DSpth <br /> Describe Material and Procedure <br /> f .I� <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 'Ithem before putting the well in use. The above <br /> ,information is true to a best of my knowledge and belief. <br /> SIGNED <br /> �u TITLE 1%G rd Aav AL4,vL- <br /> (DRAW PLOT PLAN ON REVERSE SDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY �� �� DATE D <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTIO "}` PHASE III/FINAL INSPECTION <br /> t.• <br /> INSPECTION BY DATE IAP9CTION BY _ DATE � � 7 <br /> - , <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND-VINAL INSPECT?(" <br /> E H 1426 !� ,, 4/72 1M <br />