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4 SAN JOAQUIN LOCAL HEALTH DISTRICT r <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 5,i <br /> PLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 72-- Y15 <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUER <br /> Date Issued .-� <br /> Application is hereby made to the San . <br /> (Complete In Triplicate) 00q- f/U�--1O 9y7.33 <br /> Joaquin� Local Health District for a permit to construct <br /> and/or -install the <br /> YIOrdinance Nowork herein described. This application is made in compliance with San Joaquir <br /> Count . 1862 and the. Rules. and Regulations of the San Joaquin Local Health District. '' <br /> JOB ADI RESS/LOCATI.Ot Opel <br /> A7 '/U„/lvU�P �. f��' y� <br /> I' a. CENSUS TRACT S Y7 <br /> Owner",s Name, Phone <br /> Address <br /> City <br /> Contractor's Name � c License #_?rr <br /> - Phone f <br /> TYPE' OF WORK (Check): NEW WELL F DEEPEN '/ RECONDITION / — <br /> _ _7 DESTRUCTION 1-7PUMP INSTALLATION / / PUMP REPAIR / / .PUMP REPLACEMENT / f f <br /> Other <br /> 1 f <br /> DISTANCE TO NEAREST; SEPTIC TANK SEWER LINES PIT PRIVY `�" <br /> SEWAGE DISPOSAy, FIELD CESSPOOLJSEEPAGE PIT OTHER "p <br /> IITLADEDUS f •`t <br /> TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial �e Tool Dia. of Well Excavation 1.2" T <br /> L,—Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing rte. <br /> Irrigation Gravel Pack Depth of Grout Seal" <br /> r <br /> Other � Rotary Type of Grout <br /> Other <br /> d2 <br /> Other Information, <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> H.P. <br /> PUMP REPLACEMENT: E7 State Work Done <br /> PUMP REPAIR: /7 State Work Done <br />,DESTRUCTION OF WELL: Well Diameter 72 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 abov. <br /> information true to the b of my knowledge and belief. <br /> SIGNED � - <br /> TITLE <br /> (DRAW LOT PLAN ON REVERSE SIDE— --"- <br /> PHASE I <br /> F R DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY RATE Sf�Sr <br /> ADDITIONAL COMMENTS: / <br /> PHASE II GROUT INSPECTIONPHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE 22, <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 <br /> 4/72 1M <br />