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�a <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> VICE USE: 1601 E. Hazeltori Ave. Stockton, Calif. <br /> Telephone: (209) 1466-6781 <br /> APPLICATION FOR WELL CONSTRUCTTON',OR PUMP PERMIT Permit No. 7 Z 3 <br /> THIS PERMIT EXPIRES .l Y'EAR'F'ROM DATE` ISSUED'• Date' Issued <br /> F -(Complete In,Triplicate) ,. . _•, ., i <br /> Application-)is :he _ ty3 madet.to the:;San-,Joaquin Local Health District, for =a permit'"to --Construct <br /> and/or install the work herein described. This;:-application'is, made. in .compliance with ,San'Joaquin ; <br /> County Ordinance.,Na • 18 x.an&r the-Rules'."and,Regulations •of%:t o ca dal ist ct. <br /> i.J�. •r'.{� L°: `k.; ' <br /> JOB ADDRESS/LOCATION' Z TRACT ' <br /> s ti <br /> Owner's'.Name g F 17u J s 7 fi? ri bis s. f's s" 4 r.: ,s a t .. �;Phone <br /> Address V, City . . <br /> Contractor's Name License W 47�.-�'�Phone ?96'-1 3 V 7 <br /> TYPE OF WORK (Check) : NEW WELL /01 DEEPEN '/ / RECONDITION /_/ DESTRUCTION /? <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> Other /_7 = <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 <br /> IndustrialyCa& Tool Dia. of Well Excavation <br /> 4 Lam— amestic/private Drilled Dia. of a using.f <br /> Domestic/public Driven Gauge of' Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type 4)T e o€ Grout .D <br /> „5�.....� � _ <br /> Other Other Information ' <br /> S <br /> e <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> F <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 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 /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY P DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE ISI/FINAL INSPECTI N <br /> INSPECTION BY DATE -'1 INSPECTION BY DATE Or I IdL! -1 <br /> CALL_ FOR OUT'. INSPECTION PRIOR TO GROUTING AND FINAL INSP ION. <br /> E H i426 ' , 4/72 1M C <br />