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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. Hazelton i-:Ave.-�, Stockton, Calif. <br /> FOR OFFICE USE: Telephone:, (209)-:4667`6781 <br /> 6J -73 <br /> APPLICATION FOR WELL CONSTRU,CTIONAOR PUMP PERMIT Permit No. 7 Z_- 6 <br /> t <br /> THIS <br /> IS PERXIT EXPIRES, .1 :yEAR-FROM,.DAT-E,�lS�SUED,'l,. vDdte'Issudd- -7z,� <br /> b? <br /> complete lft�-Tripatafo a y <br /> Usftic-t-If6ri�ape it t F, <br /> � ii� - 0 constrtict, <br /> Application Lig::h�-,reby-(madef to theoSan,ribaquin'�Lotal Hda-iiih Di 'Joaquin <br /> -i <br /> This­-applicatlon'jig i made. 'n,:tompfiance with: San <br /> and/or install the work herein described. lations sof ctihe,Safi,,,,Joaquin�,Local,!,H6alth 'District <br /> County-_-;Ordinance()NovqI862r.,and-,Cthe' rRu1­eS' ba-ndi_1Regu <br /> lnaq�- nj <br /> CT <br /> p NSUS;TRA <br /> JOB--ADDRESS/LOCATION <br /> rl.:;r J r_77 <br /> Owner!scNa­ <br /> 40, <br /> 7;_46 <br /> Addresspity, <br /> ., <br /> Contractorts Name License # 72, Phone <br /> DEEP-EN RECONDITION DESTRUCTION /7 <br /> TYPE OF WORK (Check.) : NEW WELC / / -- — <br /> PUMP INSTALLATION PUMP REPAIR REPLACEMENT -7 <br /> Other, / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY q� <br /> SEWAG& DISPOSAL FIELD CESSPOOL/SEEPAGE PIT . OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial. Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge' of Casing <br /> fi <br /> Irrigation. Gravel Pack Depth, of, Grout Seal <br /> Other Rotary Type of Grout <br /> other Other Information ' <br /> PUMP INS-tALLATION6. Contractor H.P. <br /> ., Type of Pump <br /> PUMP REPLACEMENT: State Work Done <br /> PUMP REPAIR: State Work Done -ib <br /> -Y�z m <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 tbe 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 /> -L � ,J <br /> 11 <br /> SIGNED _eC4_LtJ TITLE & - <br /> Q — "- <br /> t—DRAW PLOT PLAN Oly/REVERsE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> DATE <br /> APPLICATION ACCEPTED BY <br /> ADDITIONALME <br /> I COMNTS: PHASE fIT/FINAL. INSPECTION <br /> PHA4 IT GROUT INSPECTION DATE ' <br /> INSPECTION BY DATE INSPECTION BY <br /> rl U <br /> -INSPECTION. h4o <br /> GROUT INSPECTION PRIOR TO GROUTING AND FINAL <br /> CALL FORA r 4/72 im <br />