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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : '(209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION" OR PUMP PERMIT Permit No. � <br /> THIS PERMIT EXPIRES 1 YEAR 'FROM DATE. ISSUED <br /> Date Issued573 <br /> (Complete In "Triplicate) , <br /> Application is hereby made to the San Joaquin Local Health District for�,a <br /> permit anis"/or install. the work herein described. This application is made in compl ancetwith Sano const-'uJo V <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local 'Health Districtin <br /> JOB ADDRESS/LOCATI.ON <br /> L CENSUS"TR:ACT <br /> Owner's Nares / 4- —"— <br /> Phone <br /> Address $ �/ D/4/ !✓<�!.t>. Al lWaRR !� <br /> . -city <br /> Contractor's Name <br /> License. # Phone <br /> i <br /> TYPE OF WORK (Check): NEW WELL /7 DEEPEN /? RECONDITION /? DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT i <br /> Other /% <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINESt <br /> SEWAGE DISPOSAL FIELD PIT PRIVY <br /> CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL R3 ! <br /> Industrial. CONSTRUCTION SPECIFICATIONS \ <br /> Cable Tool Dia. of Well Excavation <br /> Domestic/pri.vate Drilled Dia. of Well Casing <br /> Domestic/public Driven <br /> Irrigation Gauge of Casing � <br /> Gravel Pack Depth of Grout: Seal <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: ? z.6 5->e l <br /> Contractor d <br /> �� � <br /> Type of Pump u <br /> H.P. LyL <br /> PUMP REPLACEMENT: State Work Done 3 <br /> PUMP REPAIR: / / State Work Done <br />,RESTRUCTION 0_ F WELL: Well Diameter a <br /> Approximate 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 true to the best of my knowledge and belief. <br /> SIGNED <br /> (DRA PLOT P �NRVERSE SIDE) <br /> PHASE ---- <br /> FOR DEPARTMENT USE ONLY <br /> I { <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: DATE <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE � <br /> - INSPECTION BY DATE 7 <br /> CALL FOR A GROUT INSPECTIO <br /> E H 1426 N PRIOR TO GROUTING AND FINAL INSPECTION. r - <br /> Jl 7/72 IM <br />