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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'I.SSUED " Date Issued <br /> i (Complete In Triplicate) <br /> Application is hereby Anade 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 Joaquii <br /> County <br /> Or No. 1p862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> - <br /> i JOB ADDRESS/LOCATION 0,(__G 04 4%k=R_J 14,9 ZOO 41 j!! tA1&2 ,9 jV .(Vog i CENSUS TRACT <br /> Owner's Name �� C!del Phone <br /> L 1/ <br /> Address 5-0AV IJ City.. 4-0Z>.f 14 G <br /> Contractor shame / sq' r _ License #/S a Phone 7 y_r <br /> TYPE OF WORK (Check) : ' ' NEW WELLff- DEEPEN`/� RECONDITION T/�. ._DWV4ESTRUC /7 �"��. <br /> ' PUMP INSTALLATION ZX PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK l SEWER LINES PIT PRIVY <br /> a :SEWAGE- DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER` <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS U <br /> .Industrial ; � Cable Tool Dia. -of Well Excavation 12,' <br /> Domestic/private Drilled - Dia, of Well Casing <br /> Domestic/public ' 'T + Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Groat Seal S o ' <br /> Other Rotary Type of Grout <br /> 1M Other Other Information <br /> PUMP iNSTALLATIONs Contractor <br /> Type of Pump f'.�.� - .,H.P. o� <br /> PUMP REPLACEMENT- / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> ESRTI : Well Diameter <br /> .pTUCON OF WELL <br /> -_ - _-_ _ Approximate Depth <br /> Describe Material and Procedure <br /> i <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 myk'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 /> �M <br /> SIGNEDTITLE <br /> q� <br /> (DRAW PLT PLAN ON REVERSE SIDE <br /> II' FOR ]APARTMENT USE -ONLY <br /> PHASE I' <br /> ` APPLICATION ACCEPTED BY DATE <br /> f ADDITIONAL COMMENTS: <br /> PHASE <br /> INSPECTION gy II :,OROUT INSPECTION a PHASE III FINAL INSPECTION <br /> ATE INSPECTION BY DATE 73 <br /> l�. <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> L H 1426 �� 7/72 1M <br />