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S.AN-JOAQUIN LOCAL 'HEALTH DISTRICT - <br /> :FOR OFFICE USE: 160 . E. Hazelton Ave. , Stockton., Calif. <br /> IM Telephone: , (209) 466-6781 5 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7:Z-�JS . <br /> 7 <br /> I THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED . Date Issued, <br /> (Complete In Triplicate) (j (p�- --j-5- <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> and/or-,,installl the work herein described. This application is made in compliance with San Joaquin <br /> County Drd nance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT ' S <br /> Owner's Name :�� � Q2-c�-�,r. Phone ---- <br /> ` <br /> Address y . <br /> � ��� � �*-- Cit <br /> i� <br /> Contractor s Name License I � `Phone e <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN '/ J RECONDITION /_/ DESTRUCTION /_7 <br /> PUMP INSTALLA ION -/ / PUMP REPAIR / / PUMP REPLACEMENT /_7 I�' <br /> Other 0 <br /> IV <br /> Q <br /> DISTANCE TO NEAREST: SEPTIC TANK, SEWER LINES 2 PIT PRIVY <br /> SEWAGE DISPOSAL FIELDW CESSPOOL/SEEPAGE PIT OTHER I <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation �- <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal _S V ' <br /> di <br /> Other Rotary Type of Grout <br /> I� Other Other Information <br /> PUMP INSTALLATION: Contractor i <br /> Type of Pump IV76 H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR':11' / `/ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I.hereby agrele to comply with all laws and regulations of the San Joaquin Local Health District, <br /> and the State' <br /> jof 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 DRILLERSIREPORT 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 /> II � <br /> SIGNED TITLE - -� <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> i FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> ArPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COTZ ENTS: <br /> INSPECTION �YPHAS II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> _. - DATE -R fti'y _.. �. INSPECTION BY DATE %i? •�' �.__ <br /> CALL FOR A' GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 4/72 ISM <br /> i <br />