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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOS'.=OFFTCH USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued o2-_ 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/LOCATION ENSUS TRACT - <br /> ,,. ; <br /> Owner's Name ozo ad hone e k— 4i-7 <br /> Address City 7 7 <br /> Contractor's Name License # d)a Phone g,Ld 57k!Ly , <br /> - - - — — <br /> TYPE OF WORK (Check) : NEW [BELL / DEEPEN / I RECONDITION / / DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT /7 -� <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK /061 SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD 144 r 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 / oil; <br /> Domestic/public Driven Gauge of Casing 12- w le&� <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information ' <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: j / State Work Done <br /> PUMP VPAIR: / /` State Work Donery <br /> — .0 <br /> DFRTRUCTION OF WELL: Well-DiameterApproximate 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 we11 ''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 /> TITLE <br /> SIGNED rn rntiL _.. <br /> Ik � (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> MASE I L0 <br /> a APPLICATION ACCEPTED .BY 1`� DATE <br /> ADDITIONAL COMME TS: O/ <br /> r P GROUT. INSPECTION PUM FINAL INSPECTION <br /> INSPECT ON BY , DATE �� ?--f- -7INSPECTIO DATE -�7' <br /> CALL FOR A GROUT INSPECTION <br /> -PRIOR TO GRObTING AND FINAL -INSPECTION. ' <br /> E H 1426 /731I't <br />