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JOAQUIN LOCAL IIL:ALTI- DISTRIG <br /> FOR OFFICE USE: �166 s. Hazelton Ave-. Stockton, Cai <br /> Telephone:„` (209) 466-6781 � <br /> PLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT C ' <br /> THIS,PERMIT EXPIRES 1''YEAR FROM% DATE ISSUED Date Issued <br /> ":`.(Complete In.Trip'licate) <br /> 1 Application .is .hereby made--.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 No. 1$62 and the ,Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION . o K • i� �v .Cmv a CENSUS TRACT �17 <br /> Fir <br /> Owner`s.Name &' 22 Phone 7 — <br /> Address v A0 d .S 6 <br /> f City �[ i <br /> Contractor's Name <br /> -� License # ,--Thone - 76 7( ' <br /> TYPE. OF WORK (Check) : NEW WELL FT DEEPEN / / RECONDITION /_7 DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR /�(�—PUMP REPLACEMENT /_ <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY \ ' <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> f INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONSkrl <br /> Industrial Cable Tool Dia. of Well Excavation { <br /> Domestic/private Drilled Dia.. of Well Casing <br /> Domestic/public Driven Gauge .of Casing <br />' OX _ Irrigation Gravel. Pack Depth of Grout Seal <br /> Other Rotary Type of Grout F- i <br /> Other Other Information ' i <br /> i <br /> PUMP INSTALLATION: Contractor <br /> j Type of Pump H.P. <br /> PUMP REPLACEMENT: State Work Done <br /> PUMP REPAIR: IX/ State Work Done <br /> .pESTRUCT_ION OF WELL: Well Diameter Approximate Depth <br /> r 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_ ,9/`/` <br /> J <br /> f/.. TITLE �. <br /> W PL PLANON R ERSE SIDE) <br /> DEPARTMENT USE ONLY <br /> PHASE I -7 <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE -7Z <br /> CALL k'OR A GROUT �NSPECTION.PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 �. <br /> 4/72 1M <br />