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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazeltori4Ave.:'','Stockton, Calif. <br /> Telephone.-,,�:.(209)--.1;4-66'-6781 <br /> -� APPLICATION FOR WELL CONSTRUCTION�:OR PUMP PERMIT Permit No. <br /> THIS PERM117fEXPLRES:-?.-1IYEAV FROM,DAT-R=ISSUED 70,Date:plgSu ed 29 77i� <br /> Applicat-ioti:3.-zLk:).,hdr!aby-fanadei.ta Ith-ei San J4a:quim-.lic,�al Ebrarth District;for' a-,pe�cinilt3tb,*con-struct <br /> and/or install the work herein d6scribed*.' with.,Sanv Joaquin <br /> Sail Joaquin.-.Local-*`Z?Alth,District <br /> p- :1 C, tI r, a' -1( <br /> JOB ADD RESS/LOCATION Qu j�f, <br /> -M .Phone <br /> AddressL/,14 <br /> city. <br /> Contractor's Name , License # Phone ' <br /> TYPE OF WORK (Check): NEW WELL./-';<DEEPEN I RECONDITION DESTRUCTION j7 <br /> PUMP INSTALLATION l;f7 PU1,1P REPAIR f—/—PUMP REPLACEMENT ./-7Other: F-1 <br /> f <br /> . DISTANCE TO NEAREST `SEFTIC-TANK, SEWER LINES ' PIT PRIVY <br /> SEWAG SPWAL FIELD- CESSPOOL/SEEPAGE PIT, OTHER <br /> INTENDED USE <br /> TYPE-or-WELL-. <br /> CONSTRUCTION' SPECIFICATIONS <br /> . . .Industrial- <br /> Pable.tool Dia.. ;of .Well. Excavation <br /> Y, Domestichrivate T Drilled Dia. of Well Casing <br /> p <br /> Domestic/public '' Driven' :' Gaugd,of Casing <br /> Irrigation, <br /> ........... Grave 1,Pac*k. :.Depth of. Grout Seal Y-0 <br /> Other Rotary Type :of ;Grout .-4 1 n <br /> 7p <br /> OthO-r Other Information' <br /> rume INSTALLATION : Contractor <br /> -.Type .of Pump Sub WaA,bu.- <br /> PUM REPLACEMENT- : 8 tate Work Done <br /> PUMP REPAIR: State Work D6ne <br /> ,DESTRUCTION OF WELL,,. Well Diameter Approximate Depth <br /> Describe Maierial and Procedure <br /> I hereby agree to comply -Fith-all laws and regulations of the San Joaquin Local Health District' <br /> andithe State of California pertai i�iag to or regulating well construction. Within rIFTEEN, DA)�S <br /> aft r completiori of. M <br /> Y, Work bu a new rbell, I will furnish the San Joaquin Local Health Distridt a <br /> WELL DRILLERS REPORT of the well-and 'notify them before putting the well in use. The-above <br /> informatio'n is true. to the best. of' jm6wl6dge and b lief.' <br /> my. p <br /> SIGNED <br /> TITLE!TI <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY <br /> DATE ol-;;r 7-2 1-- <br /> ADDiTIONAL COMMENTS: <br /> z <br /> PEASE II -GROVT INSPECT ON PHASE BIZ/FINAL INSPECTION <br /> INSPECTION BY <br /> DATE INSPECTION BY DATE <br /> CALL FOR A GROUT <br /> tp;rION-1&R TO,...qpMgT3;1jG AND FINAL ION. <br /> E H 1426 4/72 IM <br />