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Ir <br /> F <br /> , j SAN JOAQUIN LOCAL HEALTH DISTRICT I - <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. I ? - 31 W <br /> Telephone: (209) 466-6781 <br /> PLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit` No. 7 L 2- P' <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED , Date Issued `q <br /> (Complete In Triplicate) II <br /> Application is de to the San Joaquin Lbcal Health District for a permit to construct <br /> and/or install the work herein described. This application is made in compliance 'jwith San Joaquin <br /> County Ordinance No. 1862 and the -Rules and Regulations of the San Joaquin Local Health District: <br /> JOB ADDRESS/LOCATION e,7 G6'' CENSUS TRACT <br /> Owner's Name Phone <br /> Address City <br /> r License i �' Phone ' <br /> Contractors Name <br /> 1 <br /> TYPE OF WORK (Check) '. NEW WELL DEEPEN '/-[ RECONDITION /7 DESTRUCTION /711: <br /> -` PUMP INSTALLATION / 7 PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 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 Q <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing ! __ <br /> Irrigation Gravel Pack Depth of Grout Seal Ol _ <br /> Other Rotary Type of Grout ' <br /> Other Other Information ' ' <br /> PUMP' INSTALLATION: Contractor / d t Vis` -- <br /> Type of Pump e. H':P. <br /> i�PUMP REPLACEMENT: / / State Work Done <br /> i <br /> PUMP REPAIR: /7 State Work Done <br /> ,RESTRUCT-ION. OF WELL.---i-We11-Diameter ' Approximate Depth <br /> Describe Material and Procedure �N <br /> I hereby agree to -comply with all laws and regulations of the San Joaquin Local Health District <br /> f 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 REPO he well and notify them be£ore' putting the well in use. The above <br /> information is t e t my kn ledge and belief. <br /> SIGNED TITL <br /> (DRAW PLOT PLAN ON REVERSE SI if <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I I Z✓J/� . <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHAS RUT 'INSPECTIO PHA NAIL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE Z <br /> CALL FOR A NSPECTION PRIOR TO GROUTING AND FINAL INSP <br /> E K 1426 4/72 lM <br /> _ I <br />