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- - _ SAN JOAQ JIN LOCAL REALT.H DISTRICT <br /> FOR OFFICE USE. 1601 E. Hazelton Ave. ,` Stockton;'Calif. <br /> Telephone: , (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION Oil PUMP L N. PERMIT Permit No. 72-7 7 q , <br /> THIS PERMIT EXPIRES :I YEAR FROM DATE ISSUED Date Issued ? <br /> (Complete In Triplicate) <br /> Application is hereby de to the San Joaquin Local Health District for a -permit to construct <br /> and/or install the wo k erein described. This application is made in compliance with San Joaquin <br /> County Ordinahce-No. 1862-nnd the' Rules and- Regulations of the San J a u n i.7oc9alIHealth District. <br /> JOB ADDRESS/LOCA ION r` ;~: L`7 <br /> G.' Os-zc,-Ale;-6- F CENSUS TRACT " <br /> Owner.'s Name: t= tt me <br /> �, 7s . 1 <br /> :. 4 Phone1e4< GG i <br /> AddressT City <br /> Contractor's Name -�/ u License it Phone .-4e Qy; <br /> TYPE OF WORK (Check) : NEW WET. DEEPEN /_7 RECONDITION /? DESTRUCTION /_ <br /> PUMP INS ATION / / PUMP REPAIR ,Zg PUMP REPLACEMENT /- <br /> Other E7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD.,_._ CESSPOOL/SEEPAGE PIT OTHER <br /> 1 .. 7�~ J, <br /> INTENDED USE TYPE OF WELL_":; <br /> CONSTRUCTION SPECIFICATIONS 1 � <br /> Industrial Cable Tool Dia. of Well Excavation <br /> � X Domestic/private Drilled Dia. of Well Casing 4 <br /> Domestic/public Driven Gauge of Casing � .� <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> }� Other Rotary Type of Grout ° <br /> ,Other Other Information ' i <br /> —_. <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> - H.P. �• ��. <br /> PUMP REPLACEMENT: * / / State Work Done <br /> PUMP REPAIR: <br /> State Work Done <br /> ESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure Approximate Depth <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 s <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/ <br /> _TITLE. <br /> (DRA�,PPLOTLAN ON REVERSE SIDE) <br />-PHASE I _._j <br /> FOR DEPARTMENT USE ONLY <br /> 'APPLICATION ACCEPTED BY _ s 7 <br /> ADDITIONAL COMMENTS., DATE <br /> ��-'---- 9 <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> r <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTIO p <br /> E H 1426 4/72 1M <br /> i <br />