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r <br /> i <br /> SAN J'OAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USEI USE601 U. Hazelton Ave. , Stockton, Calif. <br /> Telephone: ..(209) 466 -6781 r <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.7 <br /> THIS PERMIT 'EXPIRES 1 YEAR FROM DATE ISSUED ; Date Issued __ �Z <br /> (Complete In Triplicate) <br /> Application is hereby 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 compliance with San Joaquin <br /> County Ordinance No. 1$52 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION L ��G dt CENSUS TRACT ' <br /> .l l� 1 ! _ <br /> ' � r' �/! �� �fZ � � Phone <br /> � <br /> owner's Name �. �j/ � _ ,,,_„_ ._...._.. ..,._..,.__.._,_ ._..._ <br /> Address .� `t'v �O D!t city <br /> Contractor's Name License # ,Z_ � 1��honee�� <br /> k <br /> TYPE OF WORK (Check) : NEW WELI. '-`, DEEPEN '/_/ RECONDITION /T7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PU11P REPAIR / / PUMP REPLACEMENT /? <br /> Other <br /> f <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> f SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> FF <br /> r <br /> INTENDED USE TYPE K WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> omestic/private Drilled Dia. of Well Casing <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 <br /> PUMP' INSTALLATION: Contractor <br /> f Type of Pump - H.P. <br /> t <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> ,DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Mate ial and Procedure <br /> 4 I hereby agree to compl ith all Laws and regulations of the San Joaquin Local Health District <br /> and the State of California: pertain,ing 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 be t of my knowledge and belief. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PRASE I <br /> APPLICATION ACCEPTED BY _ DATE <br /> ADDITIONAL COMMENTS: <br /> PRASF, ,II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE (Q-14g YINSPECTION BY DATE a <br /> ` CALL FOR A T INSPECTION PRIOR TO GROUTING AND FINAL INSPEC 0N. <br /> E H 1426 4/72 1M <br /> C - <br />