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SAN JOAQUIN Lt ;!+, sLTU DISTRICT <br /> FOR OFFICE USE: 1602 E:,i�Ha elton Ave.; Stockton, Calm. <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 <br /> f <br /> } THIS PERMIT EXPIRES 1 YEAR FROM DATA; ISSUED Date Issued <br /> (Complete In Triplicate) 2-Y(9--720-4 b <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. Thisapplication is made in compliance with San Joaquin <br /> County Ordinance No .....18{ and .:the Rules and,Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATIONi ' ��, 1 J�, J ��. ENSUS TRACT ' � � y <br /> Owner's-Name. �' Phone <br /> Address ' City <br /> Contractor's Name 14 eb i u, License # Phone <br /> TYPE OF WORK (Check) : NEW WELL A DEEPEN/_/ RECONDITION / / DESTRUCTION <br /> PUMP INSTALLATION I I PUMP REPAIR/ / PUMP REPLACEMENT /7 <br /> F Other <br /> DISTANCE TO NEAREST: SEPTIC TANK _&> SEWER LINES PIT PRIVY -- <br /> SEWAGE DISPOSAL .FIELD &Q CESSPOOL/SEEPAGE .PIT OTHER <br /> INTENDED USE TYPE OF WELL <br /> CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation _ 442 1 _ <br /> Domestic/private __ Drilled Dia. of Well Casing .J <br /> Domestic/public Driven Gauge of Casing . <br /> " - Irrigation► r _ - Gravel-Pack" Depth of'rGrout Seal`" <br /> Others( Rotary Type of Grout <br /> Other Other Information , <br /> C <br /> PUMP INSTALLATION: Contractor _ <br /> Type of Pump , - H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> ,DESTRUCTION 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 District a <br /> WELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> information is true to th st 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 DATE. /- <br /> ADDITIONAL COMMENTS: - <br /> PHA E II GROUT INSPECTION PHASE Ti/FINAL INSPECTION <br /> INSPECTION BY )ATE:'-n. C _ INSPECTION BY . DATE <br /> CALL FORGROUT INSPECTION PRIOR TO GROUTING AND, FINAL INSPE ION. <br /> E,JJ 1426 X 4/72 �j <br /> 1M <br />