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SAN JOAQUIN LOCAL HEALTH DISTRICTx ;, <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. . <br /> Xe lephone: (209) 466,-6781 3 <br /> APPLICATION,..70R. WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7J__ <br /> 4 THIS PERMIT EXPIRES 1 YEAR. FROM DATE ISSUED ; Date- Issued -/3- 7/ <br /> F (Complete In,Triplicate) <br /> Application is hereby7made 'to the, San Joaquin; Local Health District for° a .permit to construct <br /> r. and/or install the work herein described. This application is made in compliance with San.Joaquin j <br /> f County Ordinance No. 18b2 <br /> and the Rules and Regulations of the San Joaquin Local Health District,, , �. <br /> xM...CENSUS TRACT .S <br /> JOB ADDRESS/LOCATION r . <br /> '(Phone <br /> Owner's Name 3 � <br /> CityG, '� <br /> Address <br /> Contractor's Name License # 1 Phone <br /> ..+...er�.._�_. ___ v. <br /> TYPE OF WORK (Check) : NEW WELL f DE %Tf,RECOIDIT <br /> IONDESTRUCTION <br /> PUMP INSTALLATION /�/ PUMP REPAIR / /PUMP REPLACEMENT /_7 <br /> Other / f <br /> # DISTANCE TO NEAREST: SEPTIC TANK _.Eo SEWER LINES 4-17 PIT PRIVY <br /> SEWAGE DISPOSAL FIELD 7kr 2,rCESSPOOL/SEEPAGE PIT OTHER <br /> f 6 <br /> INTENDED USE . TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial h Cable Tool Dia. of Well Excavation 19. 4- Y <br /> ,K Domestic/private Drilled Dia. of Well Casing $ ' � <br /> Domestic/public Driven Gauge of Casing E� <br /> Irrigation Gravel Pack Depth of Grout Seal S Q <br /> 3 Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type: of Pump- H.P. <br /> _ <br /> 41 <br /> PUMP REPLACEMENT: / / State Work Done <br /> State Work .Donee <br /> .d <br /> PUMP-_REPAIR: �I - - - — - <br /> DESTRUCTION OF WELL: Well Diameter Approximate De th / -4 <br /> Describe Material and Procedure /`` k <br /> I hereby agree to comply with all laws and regulations of he San Joaquin Local Health District <br /> and the State- of California pertaining to or regulating well construction. Within FIFTEEN_blklS <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 the4best of my knowledge and belief. `- <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> ,FOR DEPARTMENT USE ONLY r� <br /> PHASE I DATE !-/I`7 A. <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION . <br /> I <br /> ~ " INSPECTION BY DATE <br /> NSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. 4/72 1M <br /> E H 1426 y <br />