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zMW SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOi2 0 FICE USE: 1601 E. Hazelton- Ave.', -Stockton, Calif. <br /> Telephone: (209)'. 466`-6781 <br /> cF APPLICATION FOR WELL-CONSTRUCTION'-OR PUMP PERMIT Permit No. 7) <br /> THIS PERMIT EXPIRES: l• YEAR;FROM•:DATE=ISSUED '—Date Issued <br /> (,Complete In. T-tkp'lic-ate) s. <br /> Applicatioii'D:is hereby- made.: .to the-San,-Joaquin; Local .Health District.;.for, a•permit- to construct <br /> and/or install the work herein described. This�.applicatiow i's'_made in compliance with San-Joaquin <br /> County,,Qt'dinance-•No.g1862+'and-thea Rule's'_and,-,Regulations'softhe. Sat- Joaquin Local }Health'District. <br /> .t;. Sit., <br /> JOB ADDRESS/LOCATION -TRACT <br /> CENSUS <br /> Owner's':NaTrZ")" [t, .v:: "'. i n f nIr *t a ..c o Phone <br /> Address c City., . <br /> 7= _ <br /> Contractor's VName- - Q , �r y�,. �.a ���ense # Phone <br /> . 1 <br /> TYPE OF WORK (Check) : NEW WELLDEEPEN/_/ RECONDITION /% DESTRUCTION /_7 <br /> 4 PUMP INSTIEtATION / / PUMP REPAIR / / PUMP'REPLACEMENT <br /> .Other: <br /> DISTANCE TO NEAREST: 'SEPTIC TANK SEWER LINES PIT PRIVY <br /> -SEWAGE DISP SO AL. FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> z <br /> INTENDED USE . _ TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. :of Well Excavation _/ OW� <br /> L- Domestic/private' Drilled Dia, of Well Casing fes-1 fi <br /> Domestic/public ' Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout .� <br /> Other Other Information �.., <br /> PUMP INSTALLATION: " Contractor <br /> Type of Pump 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 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 �1 �- n ,,l �, TITLE <br /> (DRA OT PLAN ON REVERSE SIDE <br /> n FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY �` DATE/4 �+ <br /> ADDITIONAL COMMENTS: ---- -- <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 w 4/72 1M <br />