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f <br /> SAN JOAQUIN LOCAL REALTH DISTRICT <br /> FOR OFFICExUS .1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6781 '1 <br /> LIGATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> j <br /> THIS PERMIT EXPIRES 1 YEAR- PROM DATE ISSUED Date Issued �_71� <br /> 5?2 nJ` 0^i11, 1�. .(Complete In Triplicate) �� D�{Q f g <br /> Application is hereby madeato the. San Joaquin Local. health District for a p�rmit to construct <br /> and/or install the work herein described. This application is made in compliance with San Joaquin ' <br /> County Ordiparice No.A862 and- the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS OCATION F77 <br /> ENSUS• TRACT <br /> Gft, er's Name' 10/7 , Q.�S Phone <br /> _� / <br /> Address 2/ ®� V� Cityv��,�-man i <br /> Contractor's Name ��1 LQ License # Os'1hone <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN / / RECONDITION / / DESTRUCTION /-7 <br /> PUN? INSTALLATION /,V PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS :. V <br /> Industrial, _ _. .Cable Tool Dia.' of 'Well Excavation <br /> Domestic/private Drilled Dia, ,of Well Casing. ., ; <br /> Domestic/public Driven Gauge of Casing <br /> lIrrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other OtherInformation (� <br /> , y <br /> PUMP INSTALLATION: Contractor t! r <br /> Type of Pump <42el H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: ' / / State Work"Done <br /> _DESTRUCTION OF WELL: Well Diameter 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 F'IFTEEN '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 i true o he bast of my knowledge and belief. <br /> SIGNED TITLE l <br /> (DRAW PLOT PLAN ON REVERSE SI E} <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I � <br /> APPLICATION ACCEPTED BY W.P+ V-0104 DATE ' f <br /> ADDITIONAL COMMENTS: { <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECT ON - <br /> INSPECTION BY DATE INSPECTION $Y DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 4/72 . 1M <br />