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- SAN JOAQUIN LOCAL HFALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. ,' Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> PLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 ) �--7 <br /> f; THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued / 1• -7 v <br /> t .(Complete -In Triplicate) { <br /> Application is Piereb ma a to the San Joaquin Local Health District for a permit to construct <br /> PP Y <br /> and/or install the work herein described. This application is made in compliance with San Joaquin <br /> County -Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION /- '� �7 / <br /> A4CENSUS TRACT 0a5- 04a'� <br /> Owner's Name l Phone <br /> Address r / 3 City <br /> contractor's Name /'.��.- .�a'�/-- . --_- License # `_)..32.3Phone <br /> IC <br /> TYPE OF WORK (Check) : NEW WELL I / DEEPEN "/ / RECONDITION /_T DESTRUCTION /_7 <br /> PUMP INSTALLATION L_1 PUMP REPAIR X/ PUMP REPLACEMENT /-7 <br /> Other / / — J <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL r CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool " Dia. of Well Excavation �. <br /> Domestic/private', Drilled Dia. of Well Casing <br /> -Do:riestic/public Driven' Gauge of Casing <br /> IrrigationGravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout , <br /> Other J ---_Other Information r <br /> .. ...i ' <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. J �" <br /> PUMP REPLACEMENT:, / / State Work Done i <br /> PUMP REPAIR: L State Work Done 4' <br /> ,DESTRUCTION_ OF W_E_LI; �l 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 <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 knowledge and belief. <br /> t - <br /> SIGNED R � TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BYJ9DATE rlZO .72-. <br /> ADDITIONAL COMMENTS: r" <br /> PHASE II GROUT`INSPECTION -� PRASE III/FINAL INSPECTION <br /> INSPECTION BY DATE `INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION4PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 — 4/72 1M <br />