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s SAN JOAQUIN LOCAL HEALTH DISTRICT 7 <br /> POR OFFICE USE: 1601 E. Hazelton .Ave. , Stockton:, Calif. wQI 72- -T <br /> Telephone: - (209) 1466-6781 <br /> PLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> THIS PERMIT. -EXPIRES .1 YEAR FROM- DATE ISSUED Date Issued <br /> .(Complete In'Triplicate) <br /> Application is hereb made-•to .the Saa;•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. -Rul,es' and: Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION (I CENSUS TRACT' ' <br /> Owners Name Phone' . <br /> Address <br /> City,.,, "4 <br /> Contractor's License # Phoned' <br /> s Name R el 44... � . . <br /> s <br /> TYPE OF WORK (Check) : NEW WELL �11�/ DEEPEN/ / RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION � PUMP $EPAIR / / PUMP REPLACEMENT /_T <br /> Other <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 6, <br /> Industrial Cable Tool Dia. of Well Excavation .�1 <br /> Domestic/private -Drilled Dia. of Well. Casing A; _ T 1 <br /> Domestic/public Driven Gauge of Casing <br /> Ij 402— <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> .Other Rotary Type of Grout <br /> Other Other Information <br /> b <br /> 1 <br /> PUMP INSTALLATION: Contractor Yp 3 <br /> Type of Pump H.P. t� <br />!4 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 /> r->—r TITLE."SIGNED /14�� <br /> - <br /> j (DRAW PLOT PLAN ON REVERSE SIDE 1 <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 7� <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT FNSPECTI N PHAS FINAL IN ECTION <br /> INSPECTION BYE �7-,- DATE INSPECTION BY DATE �_�G_.�..Z - { <br /> CALL FOR Aµ ROUT INSPECTION PR OR TO GROUTI G AND FINAL INSPECTION. <br /> E H 1426 '� rj��� 4/72 1M , <br />