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SAN JOAQUIN LOCAL HEALTH DISTRICT { <br /> FOK OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.,,7 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 5,o-,Z2- <br /> (Complete <br /> 0_��(Complete In Triplicate) <br /> Applicat-ion 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 /> JOB ADDRESS/LOCATION D f./ .p/All j CENSUS TRACT <br /> Owner's Name Phone i p,� <br /> Address `v = ! 1� City <br /> Contractor's NameLicense # Phone . - c <br /> TYPE OF WORK (Check) : NEW WELL /7 DEEPEN k RECONDITION /_� DESTRUCTION /� <br /> PUMP INSTALLATION /PUMP REPAIR / / PUMP REPLACEMENT 17 <br /> Other /-7- <br /> DISTANCE <br /> /DISTANCE TO NEAREST: SEPTIC TANK ` SEWER LINES PIT PRIVY �+ <br /> SEWAGE DISPOTE-fIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> _ Domes tic/private Drilled Dia, of Well Casing (� <br /> Domestic/public Driven Gauge of Casing h <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout _ <br /> Other Other Information <br /> .!. <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump S'-c.� H.P.... .r, <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> .DESTRUCTION 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 <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 /> SIGNED r .� t .- �r.c�' TITLE <br /> (DRAW PL LAN ON REVERSE SIDE), <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY 1A E '""" �"`,`�"� <br />`. ADDITIONAL COMMENTS: s <br /> PHASE II GROUT INSPECTION P E I F INSPE TION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSP C <br /> E H 1426 7/72 1M • <br />