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R SAN JOAQUIN LOCAL IiEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave.',- Stockton, Calif. <br /> Telephone (209) :x+66`-67,81 . <br /> E APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. -7 D 7 <br /> THIS PERMIT EXPIRES, 1 YEAR'FROM,,DATE 'ISSUED Date Issued <br /> — • (Complete 'In- Triplicate) <br /> Application' is .,herebyrmade.to thea?San Joaquin' Local Health District fora permit to construct <br /> and/or install the work herein described. This application is made-incompliance with San Joaquin <br /> County Ordinance =No.-71862. a0a,,the :Rules3and �Regulations of ;the San Joaquin Local Health District. <br /> x <br /> JOB ADDRESS/LOCATION �T�/ f �S ���9 CENSUS TRACT : <br /> : < Cd ` 7 d" C�. Phone ZIG, <br /> Owner's -Name: Z-- <br /> AddressV City "roCl� d 21/-_ <br /> Contractor's Name License Phone <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN -/ RECONDITION /_� DESTRUCTION <br /> PUMP INSTALLATION/ / PUMP REPAIR/ / PUMP REPLACEMEI /� <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK ,ja SEWER LINES PIT PRIVY <br /> SEWAGE1DISPOSAL FIELD ,,_ CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL" _ - CONSTRUCTIONgSPECIFICATIONS <br /> k <br /> Industrial Cable Tool Dia. of Well Excavation ..+�,. <br /> Domestic/private I Drilled Dia. of Well Casing [�+ <br /> Domestic/public i Driven Gauge of. Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other 1 Rotary Type of Grout <br /> I Other Other Information • <br /> t , <br /> PUMP INSTALLATION: Contractor <br /> Type .1f Pump H.P. C <br /> AC <br /> PUMP REPLACEMENT: J / State Work Done l <br /> PUMP REPAIR: / / State Work Done <br /> I ,DESTRUCTION OF WELL: Well Diameter 7 -.- _ 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 TITLE <br /> ' RAW OT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> ,, APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION P SE , <br /> F AL INSPE I <br /> INSPECTION BX DATE INSPECTION BY L.. DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPEC ION. <br /> E H-1426 4/72 1M <br /> y God` <br />