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SAN JOAQUIN LOCAL HEALTH DISTRICT � <br /> FORS FFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> LICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ' <br /> 7' / <br /> 'THIS PERMIT EXPIRES -1 YEAR, FROM DATE ISSUED Date Issued T 7 v <br /> (Complete 'ln Triplicate) i/)/ 02-,S -/70- <br /> Application is her ade to the San Joaquin' Local Health District for a permit to construct <br /> and/or install the work herein described. Th .'s application is made incompliance with San Joaquin ' <br /> County Ordinance No. 1862.and the Rules and Regulations of the San Joaquin Local Health Dfstxict. <br /> ® � � ' <br />� JOB ADDRESS/LOCATION t � � CENSUS TRACT � <br /> Owner's Name Phone '- <br /> Address <br /> p City dc/ <br /> �' _ �®`'" <br /> 7..2 3 0,5 <br /> Contractor's Name 9� License U? -Phone <br /> - ..:,. <br /> TYPE tQF-WORK_(Check) :--NEW-WELL= _DE, EPEN-=-/__7RECONDIfiION--/:�T`�DESTRUCTION F7 <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT I T <br /> Other <br /> +, DISTANCE TO NEARESTi SEPTIC TANK SEWER LINES FIT PRIVY <br /> SEWAGE DISPOSAL FIELDS CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> ( C Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal d <br /> Other - Rotary Type of Grout <br /> Other Other Information " <br /> ! PUMP' INSTALLATION: . Contractor <br /> - Type of Pump. H.P. / <br /> PUMA' REPLACEMENT: / / State Work Done <br /> PUN-P-iEPAiR: ~ ��/7 3State' Work Done " <br /> ty ,pESTRUCTION OF WELL: Well DiameterApproximate 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 fuxnishithe San Joaquin Local Health Distirict a <br /> WELL DRILLERS REPORT of ►e•1'3'" C'd"Tr G fy them before putting- thewell in use. The" above <br /> information is a best of my kn 1 g e and belief.1 <br /> SIGNED TITLE <br /> 5fgkAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I - <br /> t. APPLICATION ACCEPTED BY DATE L 7 <br /> ADDITIONAL COMMENTS: <br /> P S II G OUT INSPEC N PHASE III FINAL INSPE N , <br /> INSPECTION fYDATE 441 . INSPECTION BY -?� . DATE f <br /> CALL. FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> x <br /> 4/72 1M <br /> E H 1426 <br /> _ . <br />