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F <br /> ' 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 Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued s=jd_74- <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Hearth District for a permit to construct <br /> and/or install the work herein described. ' This application is made- in compliance with Sart Joaquin <br /> S <br /> j <br /> County Ordinance No. 1862 and the Rules and Regulations of the n Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 7/ CENSUS TRACT <br /> Owner's Name \1c.t .�. Phone <br /> I Address <br /> �l Lcr'� city <br /> NhNNINGS BROS. DRILLING CO., INC, <br /> Contr'actor's Name License # Phone <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN/ / RECONDITION I / DESTRUCTION f <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> Other <br /> DISTANCE TO DEAREST: SEPTIC TANK SEWER LINES PIT PRIVY ;* <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> t INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS � <br /> Industrial Cable Tool Iiia. of Well Excavation <br /> Domestic/private ✓Drilled <br /> Dia. of Well Casing -x <br /> Domestic/public Driven Gauge of Casing --- <br /> Irrigation Gravel Pack Depth of Grout Seal `t� <br /> Other ..- Rotary Type of Grout <br /> a Other Other Information <br /> PUMP INSTALLATION: Contractor �! <br /> Type of Pump / // H.P. <br /> PUMP REPLACEMENT: / / State Work Done ` .. _ <br /> PUMP n-PAIR: /�/ State Work none <br /> PFI-TRUCTION OF WELL: Well Diameter oximate Depth <br /> Describe Material and rocedure C <br /> f <br /> I hereby agree to 'comply with all laws and regulaci nes 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 the best of my knowledge and belief. <br /> (DRAW PLOT PL N R 'VERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE : <br /> APPLICATION ACCEPTED -BY <br /> j` ADDITIONAL, COMNTS: <br /> f PRASE 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 /> ..E H 1426 5/731M ' <br /> �� <br />