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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 07n, OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephones (209) 466-6781 <br /> APPLICAfiION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date IssuedlJ ��j <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 Ban J.Paquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local. Health D iCt. <br /> JOB ADDRESS/LOCATION L- t� �. CENSUS TRACT - <br /> Owner's <br /> RACT "Owner's Name Phoned7_,� I- S/ <br /> Address G' Cit � Q <br /> i <br /> Contractor's. Name License j-�43 U Phone 9' Y <br /> 101,1001 AV I <br /> t <br /> TYPE OF WORK (Check) : NEW ;WELL /.��EFEN / / RECONDITION /_/ DESTRUCTION /_ <br /> UMP INSTALLATION PL`MP REPAIR '/—/ PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK4 EWER LINES IT PRIVY <br /> SEWAGE DISPOSAL FIELD� SPOOL/SEEPAGE PIT OTHER <br /> �I <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS �r <br /> E Industrial Cable Tool Dia. of Well Excavation / 4 <br /> �me s tic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigations Gravel Pack Depth of Grout S Oil <br /> Other teary Type of- Grout <br /> Other Other Inf6rmation '' G <br /> Pi?v +INSTALLATION: Contractor <br /> Type of Pump c.drtK- u A~t.Fz7 H.P. . <br /> PUMP REPLACEMENT: iV State Work Done " <br /> PUMP REPAIR: / _7 _State Work Done # <br /> ,DFRTRUCTION OF WELL:. Well Diameter i ~' 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 Districtea. <br /> WELL DRILLERS REPORT of the well and notify them before putting the well in use. Tile above <br /> in ation is true to th=ofmy edgeand belief. <br /> -. . ­...;.4 �,.. <br /> SIGNED ,'. TITLE C.4 ^O CV- l - k <br /> _­(PM PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> is APPLICATION ACCEPTED-BY - d ,- DATE �=�� 7� <br /> j ADDITIONAL COIMNTS. <br /> PHASE II T ` S PION -. ?r PHASE III/YIN AL INSPECTION / <br /> INSPECTION BY DATE INSPECTION BY DATE rj �. <br /> CALL F-OR A GR UT INSPECTION PRIOR4TO GPOUTING AND -FINAL INSPECTION. <br />(` E H 1426 . . ::�� „ ' 5/731M '¢� <br />