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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: x 1601 E. Hazelton Ave. , Stockton, Calif. <br /> f Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL .CONSTRUCTION OR PUMP PERMIT Permit No. —47 <br /> I <br /> THIS PERMIT EXPIRES I YEAR FROM DATE `ISSUED : Date Issued ?i <br /> (Complete In Triplicate) <br /> Application is "he'reby•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 with San Joaquin <br /> County Ordinanca�No. 18b2 And the Rules ,arid Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION tf,F , � „. arl� CENSUSTRACT <br /> Owner's Name Phone <br /> r <br /> Cit <br /> Address y <br /> Contractor's Name e License # Phone <br /> I <br /> TYPE OF WORK (Check) : "NEW WELL /? DEEPEN '/� RECONDITION / / DESTRUCTION / 7 <br /> PUMP INSTALLATION`// / PUMP REPAIR /!/ PUMP REPLACEMENT /-7 <br /> Other. /7 <br /> DISTANCE' TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> r <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 /> t Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> H.P. <br /> PUMP REPLACEMENT: / / � State Work Done <br /> PUMP REPAIR: Stade Work Doi- - - -. . ._ } Rd - <br /> DESTRUCTION OF WELL: Well Diameter 67 Approximate Depth <br /> Describe Material and Procedure <br /> k 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 -L <br /> Gv2n. CJzCa, s [. A&1) <br /> J) TITLE a . a ire <br /> ' DRAW PLO PLAN ON EVERSE SIDE) IV <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> �J� <br /> ADDITIONAL COMMENTS: A 4z <br /> PHASE II GROUT IN ECTION _ PHASE III/FINAL INSPECTION <br /> INSPECTION BY I DATE INSPECTION BY �' O ` DATE <br /> s CALL FOR A GROUT INSPECTION PRIOR.TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 4/72 1M <br /> ' Ite <br />