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SAN JOAQUIN—LOCAL HEALTH DISTRICT is <br /> ,:POR 'OE USE: 1601 E. Hazelton Ave.- Stockton, Calif. E <br /> �� Telephone: (209). 466-6781 ! 'r <br /> APPLICATION FOR WELL CONSTRUCTION' OR PUMP PERMIT Permit No. 7 2L <br /> ' ! ,� <br /> F <br />} THIS PERMIT EXPIRES 1-YEAR FROM DATE"ISSUED Date ,issued `] T/ <br /> a (Complete In Triplicate) <br /> Application:is hereby .made to they-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. 1862 and' e RVles ,andjRegulations,of the San Joaquin Local Health District: : <br /> JOB ADDRESS/LOCATION ­rrzv� CENSUS TRACT S u 7 <br /> .Owner,'s Name. xr :;. ri ° Phone ' <br /> Address _ City '.. r <br /> Contractor's Name - License #�7/ appclo Phone (� <br /> p <br />--'TYPE--OF WORK. (Check) : NEWT L DEEPEN RECONDITION l—T DESTRUCTION /_7 <br /> PUMP INST L TION ' / 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 /> �I <br /> INTENDED USE TYPE OF WELL- CONSTRUCTION SPECIFICATIONS ;, ) <br /> Industrial _><, Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal I ' <br /> Other Rotary Type of Grout <br /> Other Other Information .41 <br /> 'k <br /> PUMP INSTALLATION: Contractor 4% <br /> Type of Pump H.P. ' <br /> PUMP REPLACEMENT: / / State Work Done p`p <br /> PUMP REPAIR: / / State Work Done <br /> . ES_TRUCTTON OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District it <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 knowledgea belief. <br /> SIGNED M <br /> r� TITLE <br /> (DRAW PLOT PLAN .ON REVERSE SIDE) ' <br /> FOR DEPARTMENT USE ONLY `j <br /> .PHASE I <br /> APPLICATION ACCEPTED BY . DATE <br /> .ADDITIONAL COMMENTS: I <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY 7O DATE 72-- INSPECTION BY-77 DATE / -E 2-'7�-- <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND=�AL INSPECTION. <br /> E H 1426 4/72 1M <br /> s! <br />