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4 <br /> °7 JOAQUIN LOCAL 11EALTH DISTRIC <br /> _F0 iOFFICE USE. 160- Hazelton Ave. , Stockton, Cal_. <br /> Telephone: (209) 466-6781 <br /> PLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7-1-d 41 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 1>-13-74 <br /> (Complete In Triplicate) <br /> Fpplication 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 Joaqui <br /> ounty Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> f <br /> rJ <br /> JOB ADDRESS/LOCATION -6 N r s �Icf a CENSUS TRACT <br /> rfwner s Name Phone <br /> Address Q yr., City <br /> Fontractor's Name a ,411Cf License ���5'S`177 Phone <br /> FYPE OF WORK (Check) : NEW WELL DEEPEN/ / RECONDITION _T DESTRUCTION <br /> �} _/ / RUCTION /_7PUMP INSTALLATION Z/ ._PUMP REPAIR/ / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK >.SQ SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE` TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial able Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> f.""-Domestic/public Driven Gauge of Casing a C <br /> Irrigation i,iGravel Pack Depth of Grout Seal �w <br /> Cathodic Protection Rotary Type of GroutF:::i <br /> Disposal *? Other Other Information` <br /> Geophysical Surface Seal Installed By: <br /> UMP INSTALLATION: ;' Contractor (� � d a Gd c, <br /> Type of Pump u 2 H.P. <br /> F�M_REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> FES•TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> 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 /> fter completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> T LL DRILLERS REPORT of the well and notify them before putting the -well in use. The above <br /> _nformation is true to the-best of my knowledge and belief. I WILL CALL FOR A.GROUT INSPECTION <br /> PRIOR TO GROUTING AND FINAL INSPECTION. <br /> �IGNE➢ 42 TITLE , <br /> DRAW PWT PLAN ON REVERSE SIDE) <br /> FOR PEPARTMENT USE ONLY <br /> ARASE I <br /> PPLICATION ACCEPTED BYy DATE Z <br /> ADDITIONAL COMMENTS: <br /> PHASE . <br /> . .Ij GROUT INSPECTION PHASE Z1/FINAL INSPECTIO <br /> rNSPECTION BY DATE INSPECTION BY72 <br /> DATE <br />