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SAI JOAQUIN LOCAL tIEALTH DISTRICT -�, -• <br /> FOR OFFICE USE: L6b14E: Hazeltori.`.Ave.' ..Stockton Calif. <br /> elephone:. , (2p9)'-.466-6781 <br /> APPLI ATIO�I FOR WELL CONSTRU•CTION:OR PUMP PERMIT Permit No <br /> 3 o Gv <br /> TH18 RMIT ,EXP,L-AES 1 •YEAR.:FROM DATE -ISSUED Date Issued �_7 <br /> =(Complete t� triplicate) <br /> Application is •hereby .made to a San.. o'aqui.n`sLocal Health District for a <br /> permit to construct <br /> and/or install the work herein•descr1bed. This:.application is made in compliance with 'San Joaquin <br /> County Ordinance No o 1862: and �t ul" and Regulations of the San Joaquin Local Health District. <br /> M : ��.:., �`C' MAY• ' <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name / :f,: f _ /'- • .. <br /> �@ Phone <br /> Address . ,!'�� � <br /> .. /� city ,, <br /> Contractor's Name License #,Za6.7YY � <br /> Phone ' <br /> TYPE OF WORK (Check): NEW WELL ' DEEPS / RECONDITION <br /> / - <br /> '/'7 DLSTRUCTTONM/'� <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 /> INTENDED USE ���...���... <br /> TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation �1 <br /> Domestic/private Drilled Dia. of Well Casin <br /> Domestic/publicg — ` <br /> Driven Gauge of Casing ,_ �. <br /> Irrigation Gravel Pack Depth of Grout Seal a <br /> Other. R � <br /> _. otary 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: 17 State Work Done <br /> ,DESTRUCTION OF WELL: Well Diameter Approximate Depth ., <br /> Describe Mat-eri,.al and Procedure <br /> I hereby agree to comp-ly with all Jaws 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 m work on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REP <br /> the well and notify them before putting the well in use. The above j <br /> information_' tothe—best—o—f-my knowledge and belief, <br /> SIGNED TITLE e,« <br /> ____ (DRAW PLOT PLAN ON 12EVLRSE SIDE) _ <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I ' <br /> APPLICATION ACCEPTEDX g � <br /> DATEt d <br /> ADDITIONAL COMMENTS: ` °� I///,/,2- <br /> PHASEGROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE /oINSPECTION BY <br /> - --•-�------- DATES-�� <br /> CALL, FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION, <br /> E H 1.426 <br /> 4/72 IM <br />