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SAN JdAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephane.-'j209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> i (Complete In Triplicate) —` <br /> Application is hereby made to the' San Joaquin Local 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 Regulations of the San Joaquin Local Health District. <br /> Il:'4L g3! S'tiuS7z .J =' <br /> JOB ADDRESS/LOCATION 2dl ©l-- U5 <br /> CENSUS TRACT <br /> Owner's NameAMMIT ..� <br /> 0 ;I Phone <br /> Address 1. . .A.�RPORT' WAY City NSA M. CA. <br /> Contractor's Name — BERN11maBROW'. License # 1:116322' Phone522 561-3 <br /> TYPE OF WORK (Check): NEW WELL DEEPEN / / RECONDITION /-7 DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR / PUMP REPLACEMENT /7 <br /> I <br /> Other N D�, <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY sj <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER (� <br /> INTENDED USE TYPE OF WELL <br /> Industrial CONSTRUCTION SPECIFICATIONS ICA! <br />---- Cable Tool Dia, of Well Excavation <br /> Domestic/private Drilled <br /> Dia. of Well Casing 1{ <br /> Domestic/public Driven Gauge of Casing <br /> X Irrigation Gravel Pack�.Depth of Grout Seal J <br /> Other t Rotary Type of Grout <br /> I Other Other Information <br /> Of1 k <br /> PUMP INSTALLATION,; Contractor <br /> Type of,,Pump <br /> H.P. r <br /> i � <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: — ., <br /> State Work Done � <br /> DESTRUCTION 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 <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 /> TELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> Lnformation is true to e b t of my knowledge and belief. <br /> iIGNED <br /> TITLE <br /> (DRA OT PLAN ON REVERSE SIDE <br /> OR DEPARTMENT USE ONLY <br />'RASE I <br />►PPLICATION ACCEPTED BY DATE <br />►DDITIONAL COMMENTS: <br /> PHASE II GP,6UT INSPECTION P�iAS I INAL INSPECTION <br /> XSPECTION BY DATE INSPECTION $Y DATE <br /> CALL FOR A GROUT INSPECTION PRIOR. TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />