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If `SAN JOAQUIN LOCAL FEALTH DISTRICT <br /> FOR^!�®FFICE USE: 1601 E. Hazelton 'Ave. ,' Stockton, Calif. 973a° <br /> Telephone: (209) 466-6751 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7a - 9G <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued �� <br /> ,1 OF �r.[ 5; ..,.:G1,/I6:✓�,L (Complete In Triplicate) c3-40 -111/ <br /> Application is hereby made to the San Joaquin Local Health District for a permit -to donstruct: <br /> and/or install the work herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 and the .Rule6 and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 2 A6Q ' CENSUS TRACT <br /> �.- <br /> Owner's Name _ � 9 ,,r,� Phone Sy 9 11A.3` <br /> T <br /> Address -- -.1` d - �7 City <br /> Contractor's Name 114444j License # o 2 Phone ' <br /> TYPE OF WORK (Check) : NEW WELL '/ / DEEPEN /—/ RE ONDITION /-7 DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT /-7 O <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY .� 1 <br /> SEWAGE 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 /> _X 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 TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) .- <br /> 7���:� FOR DEPARTMENT USE ONLY <br /> PHASE I �j <br /> APPLICATION ACCEPTED BY ° DATE P`��O <br /> ADDITIONAL COMMENTS: — -__ <br /> PHASE II G NSPE ION PHA I/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE L -3 1)'Z <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 � 4/72 I �� <br />