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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> �. FflR-OFFICE USE: <br /> 1601 E. Hazelton'Ave:,,_ Stockton,,Calif. <br /> Telephone: (209)' 466-6781 <br /> APPLICATION FOR'WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 -G7Cu <br /> THIS sPERMIT EXPIRES 4 YEAR,FROM .DATE ISSUED,-: Date :Issued, <br /> 1 `(Complete 'In Triplicate) <br /> Application"is hereby,, 'd' to ;the°San Joaquin Local Health District fora perpitjtq construct <br /> and/or install the work herein described. This''application 'is made in ,compliance with ,.San.Joagui�f <br /> County Ordinance No. 1862'-an ' the' Rules and Regulations of the San�J'oaquin•Local. Health Distxict. <br /> �. <br /> JOB ADDRESS/LOCATION <br /> • I: ,j ,� CEKSUS TRACTOwner•s Name <br /> Phone <br /> f <br /> Address <br /> f _ City.. <br /> s Contractor's Name a ' <br /> gI -5y� <br /> License # 1AW.1V Phone rn e- ,>a <br /> TYPE OF WORK,. (Check) NEW�WELL_/X/: -DEEPEN / / ._ RECONDITION /? DESTRUCTION V-7=--= <br /> PUMP INSTALLATION /7/ PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> t Other <br /> l <br /> DISTANCE TO. NEAREST: SEPTICITANK SEWER LINES PIT PRIVY <br /> .. <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT -OTHER <br /> INTENDED USE TYPE OF WELL6 <br /> Industrial CONSTRUCTION SPECIFICATIONS <br /> Cable Tool Dia, of Well Excavation <br /> .Domestic/pr-ivate t Drilled Dia. of Well Casing �� ,. �� <br /> Domestic/public 4etL <br /> P Driven Gauge of Casing _ �2 p k , ! <br /> Irrigation t 4- <br /> Gravel Pack Depth of Grout Seal <br /> Other, <br /> Rotary Type of Grout <br /> Other Other Informationn ��T <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: <br /> / / -State Work. Done <br /> ESTRUCTION OF�WELL 9- We11-Diameter <br /> APPr6,ximate"`Depth - <br /> Describe Material and Procedure ----- <br /> I'hereb a ree. to-com 1 .<with all�Iaws •and -regulations of the San Joaquin Local 'Health: District r <br /> Y� g P Y <br /> and the State of California pertaining -to or regulating well constructiozi. Within FIFTEEN DAYS <br /> after completion of my work on,-7 a new wellI 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 thexbes,t of mp knowledge and belief, r <br /> SIGNED , <br /> TITLE , <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY j <br /> PHASE I / <br /> APPLICATION ACCEPTED BY �. DATE <br /> ADDITIONAL COMMENTS: - - <br /> PHAS 1,R GROUT INSPECTION P S III INAL INS <br /> PE <br /> INSPECTION BY p (/° DATE r/_i° �l�--INSPECTION BY '� <br /> CALL`FOR.A GROUT.INSPECTION, PRIOR--TO..-GROUTING AND FINAL„INSPECTION. <br /> E H 1426 <br /> 7/72 1M ,� <br />