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= - .• SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave., Stockton, Calif. <br /> Telephone (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT &ermit No. 7 . <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED Date Issued,LLL- 7 <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. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/L:70N d 7J �f-�'LP CENSUS TRACT <br /> Owner's .NamePhoneAddress City ` <br /> Contractor's Name C,� License # jF6 ve4Phone <br /> :6®6 ' _ <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN / / RECONDITION /_� DESTRUCTION /� <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT a; <br /> Other I I <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER 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/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> E Irrigation Gravel Pack Depth of Grout Seal k <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor, 7a-67 <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: State Work Done c-,e,cJ' <br /> PUMP REPAIR: /_7 State Work Done <br /> � ,pESTRUCTION 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 my work on a new well, I will furnish the San Joaquin Local Health Distriet a <br /> WELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> information is true t the best of my knowledge and belief. <br /> !! SIGNED TITLELEF!9 <br /> /n <br /> (DRAW PLOT PLAN ON REVERSE SI <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE <br /> APPLICATION ACCEPTED BY / -- <br /> I ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> � 7/72 1M <br /> E H 1426 <br />