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SAN J'OAQUIN LOCAL HEALTH DISTRICT � <br /> fOF. CE USE: <br /> 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone:: (.209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Zy- 4 .2;4/ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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 Joaquin r <br /> County Ordinance No. I8 2 2 and the 1es dfRegul ion CENSUS TRACT of the San Joaquin Local Health District. F <br /> JOB AI3DREss1LOCATION <br /> Phone <br /> owner's Name T <br /> City ' <br /> Address <br /> License/ one <br /> 2_3-71,2 <br /> Contractor's Name <br /> TYPE OF WORK (Check): NEW WELL."X DEEPEN / / RECONDITION / / DESTRUCTION -- <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /� <br /> Other / / <br />} DISTANCE TO NEAREST: SEPTIC TALK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> TYPE OF WELL USE <br /> T, CONSTRUCTION SPECIF C TIONS <br /> Industrial Cable Toole. Dia. of Well Excavation v <br /> i Domestic/private � Y Drilled Dia. o Well Casing . <br /> Domestic/public Driven Gauge of Casing <br /> E <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> � Other Rotary Type of Grout <br /> - - Other _ Other Information <br /> pjRV INSTALLATION: Contractor <br /> H.P. <br /> Type of Pump <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / Stag Work Done <br /> ` Approximate Depth <br /> DFI-TRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure <br /> I hereby agree to comply with all Laws and regulations of the San Joaquin Local Health District <br /> 1 � , and the State of California pertaining to or regulating well''constructian. Within FIFTEEN DAYS <br /> F'w�fter completion of my work on a new we LL <br /> I will furnish the San Joaquin Local Health District a <br /> ��, ' LL DRILLERS REPORT of .the well and notify them before putting the well in use. The above <br /> {. "'Taformation is true to the best of my knowledge and belief. <br /> TITLE <br /> SINE➢ (DRAW PLOT PLAN ON REVERSE SIDE) <br /> .� FOR DEPARTMENT USE ONLY <br /> PHASE DATE <br /> h APPLICATION ACCEPTED .BY <br /> ..ADDi'TIO&AL COMMENTS: P S T /FINAL INSPECTION <br /> PHASE II G UT INSPE TZ DATE 4 !76 <br /> R INSPECT BY r DA INSPECTION BY <br /> �-/� — <br /> CALL FOO A GROUT INSPECTION•PRIOR TO GROU ING AND FINAL INSP ION. <br /> 5/731M <br />