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4i SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> _�ROFFICE U5E: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> ' 7S 1 j Q' LcJ <br /> THIS PERMIT EXPIRES 1 YEAR FROM BATE ISSUED <br /> (Complete In Date Issued,s/3 Triplicate) Ts— <br /> i Application is hereby made to the San Joaquin Local Health Distri <br /> permit <br /> and/or install the work herein described. This application is made inrc mpliancetwithnSanuJoaquin. <br /> County Ordinance No. 1862 and the Rules a d egulations of he San Joaquin Local Health District, <br /> JOB ADDRESS/LOCATION �S <br /> CENSUS TRACT <br /> Owner's Name <br /> Phon <br /> Address C> <br /> r v Cites ' <br /> [� C✓LC'-SGT E'l <br /> Contractor's Na <br /> License �'QG 03Phone4l Q3' ,cy " <br /> TYPE'OF WORK (Check): NEW WELL /.EEPEN /7 RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / UMP REPAIR _/ / PUMP REPLACEMEN—T-7 <br /> Other. /-7% <br /> DISTANCE TO NEAREST: SEPTIC TANK . "7'� WER LINES <br /> SEWAGE DISPOSAL �� IT <br /> SAL FIELD PRIVY <br /> �Gsc���CESSP00L/•SEEPAGE PIT OTHER ..�77 <br /> INTENDED USE TYPE OF WELL G 't <br /> Industrial . CONSTRUCTION SPECIFICATIONS Q, <br /> ' Cable Tool Dia, of Well Excavation Lt 1' <br /> Omestic/private �r Drilled Dia, of We11,,Casing ."` . S� <br /> Drrigaic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth -of Gro S a1 <br /> Other fotar <br /> 77 77, y Type® of Grout � - C <br /> Other Other Information <br /> r � <br /> PUMP 'INSTALLATION: Contracktor 211111 <br /> Type of Pump <br /> _} .� ,dz H.P. <br /> PUMP REPLACEMENT: '•, <br /> • / / State Work Done <br /> PUMP REPAIR: / /' State Work Done <br /> ESTRUCTION OF WELL; <br /> Well Diameter'.._ if <br /> `Approximate Depth;, <br /> Describe' Material}and Procedure s <br /> I hereby agree to comply Guth all,,laws'-and..regulations 'of the San Joaquin Local <br /> and the State,-of California pe.rtainingko mor re ulatin q 1 Health District. <br /> ction <br /> after completion of my work on a new well, 1 will furni <br /> WELL DRILLERS REPORT of the weLocalWithin <br /> DiEstrDict s 3 <br /> ll and notify them before putting 'the well in use. The above <br /> infor tion is true to the best of my knowledge and belief. <br /> SIGNED <br /> t TITLE <br /> W PLOT PLAN ON REVERSE SID� <br /> .f ' <br /> ,FOR DEPARTMENT USE ONLY <br />?RASE I j <br /> WP CATION ACCEPTED BY <br /> IDDITIQNAL COMMENTS: If 7�_ - DATE - � "` 7��� <br /> PHASE II GRO INS P CTION <br /> INSPECTION BY -DATE P 'SE III F NAL INSPECTI N f <br /> / INSPECTION BY <br /> DATE <br /> CALL A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 142626 ' <br /> V <br /> /72 1M <br />