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r <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OF iCE USE: 1601 E. Hazelton Ave. , Stockton, Calif <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMPPERMIT rmit , ; 3 .. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued . <br /> f• <br /> A� Z I kf 6#uJ4 �8. (Complete In Triplicate) �►°.� ' qC Q- /7�—0(v <br /> pplication,is hereby tmade 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. 1862 and the ,Rules and Regulations of the San Joaquin Local Health District. I" <br /> JOB ADDRESS/LOM:ta CENSUS TRACT <br /> Owner's Name 7 <br /> Phone �}b 9—30 1 <br /> Address r <br /> a-�-e— city <br /> Contractor's Name License #AU2 Phone3 L,? <br /> l �~ <br /> j. <br /> TYPE..OF. WORK-(Check) : _NM.WELL '/.�, ',DEEPEN '/_7 RECONDIT.ION.�-/-7—t—DESTRUCT�UN /?� <br /> PUMP INSTALLATION /-/,-PUMP REPAIR PUMP- REPLACEMENT /? <br /> Other /`/ ' _ - �1 1 <br /> DISTANCE TO NEAREST: SEPTIC TANK ._ \SKWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIEI.I}* CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL r CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation +L <br /> Domestic/private Drilled Dia. of Weil Casing' <br /> Domestic/public Driven Gauge'of Cjsing <br /> _ .>L_Ir,rigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> I <br /> PUMP INSTALLATION: Contractor ,Q. �, <br /> Type of Pump <br /> -- �G. (r H.P. �IS- <br /> PUMP <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: State Work Done ` <br /> .LESTRUCTION OF WELL: We11' 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 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 i true to the best ofmy knowledge and belief. <br /> SIGNED TITTLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> F DE <br /> PHASE I T USE ONLY. <br /> r , <br /> APPLICATION ACCEPTED B C� . DATE *Y� <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE — <br /> CALL FOR .A_GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> . E H 1426 <br /> 7/72 1M <br />