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SAN JOAQUIN LOCAL HEALTH DISTRICT [ <br /> POT,- <br /> USE: 1601 E. Hazelton Ave. <br /> ° , Stockton, Calif. <br /> Telephone:;. (209) 466-6781 <br /> AP ICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 _gA:-' <br /> THIS PERMIT EXPIRES. I YEAR FROM DATE ISSUED Date Issued Ii- t�:76 <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 Joaquim� <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT�/� <br /> Phone <br /> owner's Name <br /> 10 City . <br /> Address) <br /> a. . <br /> Contractor's N rye � <br /> License Phone? <br /> TYPE OF WORK (C eck) : NEW-TELL DEEPEN / / RECONDITION / / DESTRUCTION /-7 <br /> PUMP INSTALLATION I l PUMP REPAIR'/ / PUMP REPLACEMENT 1-7 <br /> Other / / <br /> DISTANCE TO NEARE T: SEPTIC TANKSEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD �y CESSPOOL/SEEPAGE PIT OTHER <br /> " `` . INTENDED U TYPE OF WELL <br /> CONSTRUCTION SPECIFICATIONS <br /> Industrial _ Cable Tool Dia. of Well Excavation. /h_`. . --l_ <br /> Domestic/ rivate Drilled Dia:.-off#Well=Cas'in`g+ <br /> Domestc�/p =� "'� ` rven <br /> Gauge of Casing <br /> asing <br /> "`- Gravel Pack Depth of Grout Seal <br /> .� Irrigation �---• <br /> Type of Grout <br /> Other Rotary - <br /> "� Other Other Information <br /> t <br /> PUMP INSTALLATION: Contractor F H.P. - <br /> Type of Pump <br /> PUMP REPLACEMENT: / / State Work Done <br /> POMP 'RZPAIR: /% State Work Done Q <br /> i DFvTRUCTION 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 /> ' land the State of California pertaining to or regulating well "construction. Within FIFTEEN DAYS <br /> I 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 /> sinformation is true to the best of my knowledge and belief. <br /> { <br /> TITLE <br /> SIGNED <br /> E (DRAW .PLOT PLAN ON REVERSE SIDE) <br /> F. DEPARTMENT USE ONLY <br /> A PHASE IBATE <br /> APPLICATION ACCEPTED "BY <br /> ADDITIONAL COMMENTS: p M <br /> AL NSPECTIO <br /> PFiAS I GROUT INSPECTION_ <br /> . <br /> INSPECTION BY DATE INSPECTION BY TE <br /> CA3:L FOR A ROUT-INSPECTION-PRIOR,TO GROUTING AND FINAL IN ECTION5X73 <br />