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SAN JOAQUIN LOCAL HEALTH DISTRICT C �� <br /> FOIN OFFICE USE: 1601 E. Hazelton'Ave.;, .Stockton, Calif". <br /> Telephone:' (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION`rOR PUMP PERMIT Permit <br /> THIS PERMIT.EXPIRES 1iYEAR'IFROM DATE ISSUED Date Issued <br /> `���� '(Compl'ete lh:-Triplicate) <br /> Ap licatioi�l ifsl) erebyxmade-i.to :the,.)San5Joaquin" Local Health District for a permit to construct <br /> and/or install the work herein described. Thi& applic-ation, is made in compliance with San Joagt <br /> County.,.Ordinance. No:i1862r.and}the ,Rules and',Re'gulations of the San Joaquin Local- Health District <br /> > a"2' .. t;• X>i�.X v,... =ty �.!! 3.t.� �r `.•.. b's .`��.:r. a ry) ` <br /> JOB ADDRESS/LOCATION. �a 3 C ?�G�I Yc o[ CENSUS- TRACT ' <br /> ur <br /> Owner's',Name•:J / '�'� y7iG l ?"Gt i.F, o .. r Phone ,,22- 5-227 <br /> x o <br /> Address lQ_� C_l�t� �l Utie�la s� rcf�� City <br /> C � E5 <br /> j- r <br /> Contractor's Name J �o / K// Licensea3I,��Phones / L <br /> —.TYPE-OF.WORK (.Check) NEW WELL ' DEEPEN /_7 RECONDITION /_7 DESTRUCTION /7 <br /> " PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT • <br /> Other / / x ! <br /> DISTANCE TO NEAREST: SEPTIC TANKSEWER LINES --- - PIT PRIVY <br /> SEWAGE DISPOSAL FIELD — CESSPOOL/SEEPAGE PIT OTHER <br /> ! INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> ' Domestic/pr-ivate Drilled Dia. of Well Casing ` <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal _ <br /> Other V;:...r', Rotary Type of Grout 61L E_ <br /> Other Other Information <br /> F t <br /> S <br /> PUMP INSTALLATION. X Contractor tA �v- <br /> "� Y\ Type of Pump ' k w H.P <br /> PUMP REPLACEMENT: L/ State Work Done <br /> PUMP REPAIR: � �..� �/ / State Work Done <br /> DESTRUCT-ION OF. WELL:, Well Diameter- _ Approximate- Depth <br /> Describe Material and Procedure <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 <br /> after completion of m work on a new well, I will furnish the San Joaquin Local Health District <br /> WELL DRILLERS P RT f t e well a y them before putting the well in use. The above <br /> information i t e o t of my 'knowle'dge and belief. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SID <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY t" �: DATE .2G <br /> ADDITIONAL COMMENTS.: <br /> PHASE II GROUT INSPECTION PHA F AL INSPECTION <br /> INSPECTION BY . DATE INSPECTION `BY DATE <br /> CALL__ FOR A GROUT. INSPECTION PRIOR•TO GROUTING ANDtFINAL, INSP TION. ; <br /> E H 1426 ; 'ilr . I . . 4/72 1M <br />