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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F,C�t. C 'ICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> PLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. LL/ 5 a <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued r 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 /> 7 <br /> JOB ADDRESS/t9e*T%*N 7e ` <br /> _-- C�j! �t e6_;l CENSUS TRACT <br /> Owner's Name r i'�77_C' .S Phone <br /> Address Mee City <br /> Contractor's Name s rS License ? � J��� <br /> Phone <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN / / RECONDITION I_T DESTRUCTION <br /> PUMP INSTALLATION /Y[—PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other /_7 T` <br /> DISTANCE TO NEAREST: SEPTIC TANK' 14-SEWER LINES//Q fi PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> j� Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> OtherRotary Type of Grout <br /> Other Otherformation <br /> T ��5 I 7 6 <br /> PUMP INSTALLATION: Contractor / ,SS <br /> Type of Pump �, H.P. <br /> PUMP REPLACEMENT: / / State Work Done ` <br /> _ o <br /> PUMP REPAIR: / / State Work Done A t <br /> ESTRUCTION 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 the best 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 DATE7 A� <br /> ADDITIONAL COMMENTS: fa 42 <br /> P GR INSPECTION PHA5#0t1YVNAL INSPECTION <br /> INSPECTION BY DATE =yg INSPECTION BY DATE ��� <br /> CALL FOR I PE ION PRIOR TO GROUTING AND FINAL INSP C <br /> E H 1426 ' 7/72 1M <br />