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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> t FOLIOFFICE 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 l YEAR FROM DATE ISSUED Date Issued �3 <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 Joaqui <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health 'District. <br /> I JOB ADDRESS/LOCATION 7Er7�, � ---- � , L b � CD, CENSUS TRACT <br /> j owner's Mame VQe,kzja _S_Z6-%_142 . .... Phone �5 _<3� 3y 7 <br /> Address -- cc --- �e-- , r City m7jr;jrs To -_ <br /> Contractor's Name �„ .z! _. .._ ._ License oA�Phone <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN J RECONDITION /_/ DESTRUCTION /-7 <br /> PUMP INSTALLATION /lf PUMP REPAIR/ / PUMP REPLACEMENT /_7 <br /> Other <br /> DISTANCE TO DEAREST: SEPTIC TA','K SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> I <br /> ! INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS pp+� <br /> Industrial Cable Tool Dia'." of Well Excavation "I <br /> i -- Domestic/private ( -Drilled .. .Dia: of Well Casing <br /> Domestic/public Driven Gauge'ofbCasing <br /> Irrigation Gravel Pack Depth of--Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> i PUMP INSTALLATION: Contractor <br /> Type of Pump 56.� H.P. „ <br /> s PUMP REPLACEMENT: / / State Work Done <br /> 3 <br /> UMP UPAIR State <br /> Pr Work Bone <br /> DFRTRUCTION OF WELL:� Well Diameter Approximate 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 furnish the.-San .7oaquin 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 th best of my knowledge and belief. <br /> `= SIGNED TITLE <br /> (D PLOT PLAN ON REVERSE SIDE) <br /> f R DEPARTMENT USE ONLY <br /> PHASE 1 , t <br /> APPLICATION ACCEP'TE Y DATE /7 'e. <br /> ADDITIONAL CO <br /> P I O PIC P S II INSPECT ON <br /> INSPEC ION BY ATE INSPECT DATE --� <br /> is CALL FOR A GROUT I PECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 5 I.7 3-[m <br />