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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 /> 1 APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -IZ22-2, <br /> - (Complete In Triplicate) T- <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 Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION / - n f �/ b1 ENSUS TRACT <br /> i <br /> Owner's Name 2., ,- Phone �o <br /> Address / ' -�_ city -� a it` <br /> Contractor's Name. ` 7 rLrc� License # /6 :C-i2. Phone <br /> TYPE OF WORK (Check) : NEW WELL /-7 DEEPEN /_/ RECONDITION /-7 DESTRUCTION <br /> PUMP INSTAL TION / / PUMP REPAIR / / PUMP REPLACEMENT-- /7 <br /> Other iC*T `A4" <br /> PLO- <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 <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> 1 <br /> > Irrigation Gravel Pack Depth of Grout—Seel—, --�. C Other Rotary Type of Grout <br /> Other ! Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of -Pump �'�, „ ..,, . ,. ..,..„,. H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: �/�{ State Work Done a� <br /> 3 <br /> ESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> J <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 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 bewst of my knowledge and belief. , <br /> SIGNED �� � /'�r- �'�`�f- TITLE -' <br /> — —-- - '- (DRAW PLOT PLAN ON REVERSE SIDE) T <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ` ADDITIONAL COMMENTS: <br /> PHASE IS ROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE �. <br /> CALL FOR A GRO INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />