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Y• Y SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFUCE USE: 1601 E. Hazelton Ave. ;.. Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> ' PLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. _5 Z �. <br /> THIS PERMIT EXPIRES .1 YEAR FROM DATE 'ISSUED Date Issued-.6- �- 12-; <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.0rdinance N1862 and the Rules-and Regulations ,o a San< Joaquin Local Health District. <br /> ;3:0$ ADDRESS/LOCAT CENSUS TRACT S 'f 7 <br /> .Owner'.s Name` ' , Pho -- <br /> 411d <br /> Address City <br /> Contractor's Nameicense han <br /> TYPE OF WORK (Check): NEW WELL DEEPEN '/_7 RECONDITION /_7 DESTRUCTION'/-7 <br /> PUMP IN CATION / / :PtTMP�REPATR / / PUMP-REPLACEMENT / J <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES tl <br /> QV PIT PRIVY <br /> SEWAGE DISPOWC FIELD CE POOL/SEEPAGE PIT OTHER <br /> m � <br /> INTENDED USE TYP4 PF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation �7 <br /> Domestic/private Drilled Dia. of. Well Casing 9 <br /> Domestic/public Driven. Gauge of Casing <br /> J Irrigation Gravel Pack Depth -of Grout Seal <br /> �4 Other Rotary Type of Grout <br /> Other Other Information " <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> ,DESTRUCTION OF WELL: Well Diameter �..r Approximate a Depth � <br /> �--�- = Describe Material and Procedure — <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 them before putting the well in use. The above <br /> information is rue to t e best my knowledge and belief. <br /> SIGNED TITLE <br /> {DRAW MOA PLAN ON REVERSE SIDE <br /> R DEPARTMENT USE ONLY <br /> PHASE I } : <br /> APPLICATION ACCEPTED BY _ DATE <br /> ADDITIONAL COMMENTS: ' <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE -7 <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H I426 - 4/72 1M <br />