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SAN ,1OAQUTN LOCAL HEALTH DISTRICT <br /> FOR OFFICE US Stockton <br /> 1601;E.. Hazelton Ave. , <br /> Calif - <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. f <br /> �. Z Z THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquih�Soalstruct <br /> District <br /> made infor <br /> compliancetwith nSan Joaquin <br /> and/or install the work ',herein described. T application <br /> County Ordinance No. 18fi`Z and the Rules and Regulations of t�S n Jl��i Loco health District. <br /> Q✓L CENSUS TRACT <br /> JOB ADDRESS/LOCATION 'a r f� �i�____� a►! ' Ai �� +ci� <br /> o✓fi�i Phone <br /> Owner's Name <br /> City <br /> Address _4X <br /> License # / 7z,�'Phone ga 7v <br /> Contractor's Name S',La u1 <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN. / RECONDITION / ESTRUCTION <br /> REPLACEMENT/7 <br /> PUMP INSTALLATION / / PUMP REPAIR /�C/ PUMP <br /> Other <br /> l <br /> 11. . <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER �. <br /> : -- -� - - <br /> INTENDED USE ! TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> F Industrial , Cable Tool Dia. of Well Excavation <br /> rivate Drilled Dia, of Well Casing ' <br /> Dorreestic/p Gauge of Casing <br /> � ' Driven g g <br /> Domestic/public <br /> l GravePack Depth of Grout Seal <br /> Irrigation ; i <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> � uM, <br /> PUMP INSTALLATION: Contractor H.P. <br /> Type of Pump r____�t� <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> , DESTRUCTION OF WELL. ,Well Diameter <br /> 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,; wore well. and notifyn a new well, lthemlbeforesh the puttingatheowellninouse.cal HeThehaboverict a <br /> I WELL DRILLERS REPORT of th <br /> information is true to: the best of my knowledge belief. <br /> , 01 <br /> SIGNED i ITLE /- <br /> (D PLOT LAN ON R ERSE SIDE <br /> FOR EPARTMENT USE ONLY j <br /> PHASE I �. DATE <br /> APPLICATION ACCEPTED BY <br /> , ADDITIONAL COMMENTS: I. PHAS III FI INSPECTIO <br /> PHASE IIj�GROUT INSPECTION INSPECTION BY DATE l <br /> i INSPECTION BY _ if DATE <br /> CALL FOR A GROUT INSPECTION PRIOR..TO GROUTING AND FINAL INSPECT 7/72 . 1M <br /> x 11, <br /> E H 1426 ' <br />