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S1 JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 7y-SYy G' <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.p�,_e~��e <br /> .THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) i -,�, <br /> a permit <br /> ct <br /> Application is hereby made to the San Joaquin Local Health District inrCompliancetwith SanuJoaquin <br /> and/or install the work herein described. This application x <br /> Count Ordinance -No. .1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> County 1/ <br /> C 25'15* 2. :S ...rAo" ,„ l OS CENSUS TRACT <br /> 1`JOB ADDRESS/LOCATION 2 <br /> Phone � L7 3L <br /> Owner's Name�a0 <br /> ,, / city /% <br /> y <br /> Address �} (� o/ <br /> /�j <br /> Contras <br /> tot's Name1!27iC License # o(�� �Jxaone �" i <br /> NEW- WELL ��- DEEPEN..;../=T�,-RECONDITION_-/_�—DESTRUCTION:/��- -- <br /> TYPE OF WORK�_(Check} � - <br /> " ' PUMP INSTALLATION PULP REPAIR / / PUMP REPLACEMENT IST <br /> Other <br /> SEWER LINES --� PIT PRIVY �� f <br /> DISTANCE TO NEAREST: SEPTIC TAN R LINES <br /> PIT OTHER <br /> SEWAGE DISPOSAL FIELD <br /> INTENDED USE TYPE OF WELL <br /> CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Dia. of Well Casing <br /> Domestic/private Drilled <br /> Driven <br /> Domestic/public Gauge of Casing <br /> ravel Pack Depth of Grout Se 1 <br /> Irrigation <br /> Other �otary Type of Grout <br /> ( - - Other Other Information <br /> 1 1 <br /> PUMP INSTALLATION: Contractor d 7 H.P. j, <br /> Type of Pump <br /> k <br /> PUMP REPLACEMENT:' / / State Work Done 1 <br /> } PUMP REPAIR: / / State Work Done <br /> `App-o�ir►iate'Dep'th <br /> ;DESTRUCTION-�OF"WEI�I: DescribemMaterial andProcedure <br /> i <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> and the State California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> after co ion f my work on a new wrell I will <br /> il lbfurnishefore putting the <br /> Joaqui <br /> wellnin use. <br /> cal HeThe <br /> habove <br /> xict%a <br /> WELL D LLERS RE RT of the . el and notify <br /> infor tion is rue to t e k7 <br /> �11 <br /> of .my knowledge and belief. <br /> TITLE <br /> I SIGNEDL� <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> 1 FOR DEPARTMENT USE ONLY <br /> PHASE I DATE <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: PHASE III/FINAL INSPECTION <br /> PHASE II GROUT INSPECTION INSPECTION BY DATE <br /> INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION aOR,TOG U NGAL INSPECTION. 4/72 1M <br /> E H 1426 <br />