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1 4k <br /> oud <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> r SOF. OFFICE USL: 1601 E. Hazelton Ave. , 'Stockton, Calif. <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> 72_ L*) <br /> 710 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued a aµ >> <br /> (Complete In Triplicate) jCoo—2-C <br /> Application is hereby made to the 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 the Rules and Regulations of the San -Joaquin Local Health District. <br /> .TOB ADDRESSJLOCATION_�, NSUS TRACT <br /> 41 <br /> sJ <br />` Owner's Name -44 14 , Phone <br /> Address City <br />` Contractor's Name /� License }�i 'Phon � <br /> TYPE OF WORK (Check): NEW WELL M DEEPEN/ / RECONDITION {_/ DESTRUCTION f7 <br /> PUMP INSTALLATION PUMP REPAIR ,/ / 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 CONSTRUCTION SPECIFICATIONS <br />} Industrial Cable Tool. Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing 747 1 <br /> Domestic/public Driven Gauge of Casing <br /> t Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information - <br /> PUMP INSTALLATION: Contractor <br /> f <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> 'PUMP'uPAIA: 1-7-'State Work Done <br /> DFgtRUCTION OF WELL: Well Diameter Approximate Depth <br />{ Describe Material and Procedure <br />�I 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 /> p� information is true to the. ;best of my knowledge and belief. <br /> 'SIGNEDTITLE <br /> CY .(DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PEASE I <br /> APPLICATION ACCEPTED .BY DATE "` <br /> ADDITIONAL COMMENTS: <br /> F E IL GROUT INSPE ION PHASE II/F- NAL INSPECTION <br />> INSPECTION BY DATE INSPECTION BY . DATE : _z <br /> CALL-FOR-A• GROUT?-INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> x tea 15/731-M <br />