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.J t00..r. <br /> SAN JOAQUIN LOCAL HEALTH ;DISTRICT <br /> FdR..OFFICE USE: 1601 E. Hazelton`Ave.,', Stockton, Calif. <br /> Telephonie. (209) 45h-0781 <br /> APPLICATION FOR WELL. CONSTRUCTION,ORt PUMP PERMIT Permit No. <br /> r - f <br /> �p THIS PERMIT a:EXPIRES',i YEAR:°PROM'`DATE 'IS SUED Date Issued <br /> 6`— (Complete In�_Triplidhte) _ <br /> Applicati-on;..xs,heroby.Amade'kto.Ithe.San�,,JoaquinllLocal Health District for a permit to construct <br /> and/or install the work herein- described. This_.applicat .on. is made in compliance with San Joaquin.' <br /> County.Ordinance -No ,1862:.and11 hw.Rules'andrRegulations -of'the San 'Joaquin•Local Health District. <br /> JOB ADDRESS/LOCATION 1L CENSUS TRACT S" <br /> .X.r Ia{ ;c7 tt,1ni$..j 'LI Q' <br /> - 3 ` ` : <br /> Owners NamecU z4' )k. s r:, a <br /> Phone <br /> 2, i <br /> - _.�. <br /> Address l 6 City. _ <br /> Contractor's' Name - License # Phone ^ Sym <br /> yS)a <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPENL/�/ RECONDITION ,/_7 DESTRUCTION /_7 <br /> PUMP INSTAI:L:ATION/Y/ I�UfP—REPAZ�t:/' / ':FUNfP REPLACEMENT I� <br /> Other. f a <br /> DISTANCE TO NEAREST: SEPTIC TANK ys'`" SEWER -LINES PIT-'PRIVY <br /> SEWAGE DISPOSAL .FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> wow I <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS `J <br /> C <br /> Industrial K Cable Tool - Dia. of Well Excavation CM <br /> Domestic/private -q,Drilled Dia. of Well,,Ca-sing <br /> Domestic/public . € Driven Gauge of lasing /",L— <br /> Irrigation <br /> ,L—Irrigation T.. .,_ : 1. Gravel Pack Depth of Grout Seal <br /> Other ; F Rotary Type of Grout <br /> 1 Other;` C'-"`Other Information — — I <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump—per.., -:,.... - H.P. ..� <br /> PUMP REPLACEMENT•/ /. 'T State Work "Done <br /> PUMP REPAIR: /' / State"Work Done <br />,DESTRUCTION OF WELL: Well Diai6eter Approximate Depth <br /> "Describe Mater:al- and"Pradedure <br /> I hereb�lagree -to�'comply with .all .laws and regulations of the San lJoaquin 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 riew well, I will furnish the San 'Joaquin Local Health District1a <br /> WELL DRILLERS. REPORT of the Well�andLnotifj,ihem. befoie putting the well in use. The above <br /> information is true to the best of my knowledge and belief. <br /> SIGNED TITLE '; <br /> (DRAW PLOT PLAN ON REVERSE� SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> .PHASE I <br /> APPLICATION ACCEPTED BY r DATE <br /> ADDITIONAL COMMENTS: <br />-. PHASE II GROUT INSPECTION , PHAS I I[FINAL INSP,ECT.109 A ,u <br /> INSPCCTION, BY DATE INSPECTION BY DATE .-- z= --•� <br /> :yCALL FOR A.GROUT INSPECTI.ON,_PRIOR_TO GROUTING.AND FINAL.-.INSPECTION. _ <br /> E H 1426 4/72 1M <br /> - c <br />