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o <br /> ' SAN. JOAQUINFLOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> F <br /> Telephone : (209) 466--6781 <br /># APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. !1J <br /> s <br /> k THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued / _ <br /> i (Complete In Triplicate) �0Q.- s'r <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 /> 7.,& <br /> JOB ADDRESS/LOCATION '''' CENSUS TRACT S _ <br /> Owner's Name jf '' Phone <br /> Address City <br /> Contractor's Name License # Phone > <br /> p ,2c� �3� �.�_yd, <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN /% RECONDITION /?p DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> Other / / }. !_ Jp� 4 - <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY o� <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGEPIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS C, <br /> Industrial ' Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing & h <br /> Domestic/public Driven Gauge of Casing ] ,0j,;(, <br /> _ Irrigation Gravel Pack Depth of Grout Seams"w , <br /> Other Rotary Type of Grout l I we '';.1p �gf <br /> Other Other Information -6�7 """o I <br /> PUMP INSTALLATION;. — <br /> Contractor <br /> Type of Pump I it t H.P. p <br /> PUMP REPLACEMENT: / / State Work Done - <br /> _,PUMP—REPAIR-:w..�:- -• �:..� .. - State=Work Done} <br /> .ESTRUCTION OF WELL: Well. Diameter . Approximate Depth <br /> F. �� Describe Material andgPiocedure 1 <br /> I hereby agree to comply with�,allilaws and regulations of •the San'Joaquin Local Health District <br /> and the State of California pErtaining to or regulating well cons't-r tion. Within FIFTEEN DAYS <br /> after completion of my work on%aN a well,.,1w�illtfurnish the Sand/Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the we l'1 anenotify Ne& before putting the well in use. The above <br /> information is true to the best of my knowledge atid` belief. <br /> SIGNEDI i TITLE' <br /> { (DRAW PLOTIPLAN ON REVERSE SIDE)l <br /> FOR DEPARTMENT USE ONLY <br /> t. PHASE 1 : <br /> , ,APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE I GROUT INSPECTION P IgaINAL INSPECTION <br /> INSPECTION BY DATE INSPECTI Y DATE — <br /> CALLiFOR A GROUT INSPECTION PRIOR,TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M 3Y <br />