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T. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , -8tockton, Calif. <br /> Telephone: (209) 4:66-6781 " <br /> 41 C4QAPPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.tF <br /> . 7 7i .5 Z7 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Ii. Date Issued <br /> (Complete In Triplicate) <br /> Application is.hereby.madeito the San Joaquin Local Health District fora 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 /> JOB ADDRESS/LOCATIONy �rl CENSUS TRACT ' r <br /> Ownei's.Name': 40� <br /> .�,.�' ,o Phone <br /> Address ACity <br /> �t, Ie, <br /> I <br /> Contractor's Name cense # Z y Phone jg2,,74 <br /> TYPE OF WORK (Check) : NEW WELL-/ /- DEEPEN '/-7/ RECONDITION /_/ --DESTRUCTION-/-7 <br /> PUMP INSTALLATION / PUMP REPAIR/ / PUMP REPLACEMENT /_7 <br /> Other /_7 <br /> II <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRU TION SPECIFICATION '; �o <br /> Industrial Cable Tool Dia. of Well Excavation (A <br /> -- ti <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information f <br /> '( <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump : H.P. <br /> i <br /> PUMP REPLACEMENT: ! <br /> State Work Done • <br /> PUMP REPAIR: / / State Work Done - <br /> 'I 1 <br /> ,DESTRUCTION OF WELL: Well DiameterF ___.� _ _ :_:_ __ - -. = Approximate-sDepth`-'--,---- <br /> . Describe Material and Procedure , <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District 1 <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 knowJ:ed e and belief. <br /> SIGNED ., TITLE <br /> £( W P '0 PLAN ON ERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY f . DATE i <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION P I/ INAL INSPECTION— <br /> INSPECTION <br /> NSPEC ION INSPECTION BY © DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION." <br /> E H 1426 4/72 1M <br /> li� <br />