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;SAN JOAQUIN LOCAL HEALTH DISTRICT ~` --• <br /> FdR OFFICE USE: 1601E.' Hazeltoh-• Ave,' '•Stockton Calif. <br /> elephdhe (209),.466.6781 <br /> APPLI AT•ION' FOR WELL CONSTRUCTION'-OR PUMP PERMIT Permit No.7 " Sp , W <br /> r <br /> THIS RMIT ,EXPMAES 1 YEAR.'FROM DATE -ISSUED Date Issued <br /> ;(Comp1ete.Ih,Triplicate) <br /> Application is 'hereby .made co a 5an•JoaquknsLocal Health District for a permit to construct <br /> and/or install the work herein-described. Thi-s•.applitcation is made in compliance with 'San Joaquin <br /> County Ordinance No:=1862: and ,t - u_l" and Regulations of the San Joaquin Local Health District, <br /> JOB. ADDRESS/LOCATION <br /> CENSUS TRACT <br /> Owner's Name 'ri I�f�'• . ;, ;;. Phone <br /> Address , Xl�d City <br /> Contractor's Name License &&07,93-'Phone <br /> TYPE OF WORK (Check): NEW WELL DEEPEN '/-/ RECONDITION -/-7-DESTRUCTION/_7 <br /> PUMP INSTALLATION;, PUMP REPAIR I / PUMP REPLACEMENT /-J <br /> Other - <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL <br /> Industrial CONSTRUCTION SPECIFICATIONS <br /> Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Other ea <br /> Irrigation Gravel Pack Depth of Grout Sl__ <br /> Rotary Type of Grout <br /> Other Other Information N1. <br /> PUMP INSTALLATION: Contractor �`� � , r - <br /> Type of Pump - - r <br /> +�! H.P. <br /> _�S <br /> PUMP REPLACEMENT: %/ State Work Done <br /> PUMP REPAIR: /% State Work Done <br /> ,DESTRUCTION OF WELL: Well Diameter <br /> - Approximate Deptb- <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 _M work on a new well, I will furnish the San Joaquin Local Health District a f <br /> WELL DRILLERS REP of the well and notify them before putting the well in use. The above <br /> informatio- ue to"theb-best-of-kmy knowledge and belief, k <br /> SIGNED � , I <br /> F-�, - TITLE �.MG„ <br /> f(DRAW PLOT PLAN ON REVERSE SIDE) <br /> PHASE I FOR DEPNT USE ONLY ; <br /> APPLICATION ACCEPTED B'Y! f/ DATE / t/ <br /> ADDITIONAL COMMENTS: � <br /> PHASELI GROUT INSPECTION., PHASE III/FINAL INSPECTION <br /> INSPECTION BY V DATE /o <br /> 7 INSPECTION BY IlaDATE ,�. - S-� r ; <br /> CALL FOR GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 4/72 1M <br />