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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 /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. q_I S.Z_!l <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ,T_�2G-7q- <br /> t (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 <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local. Realth District, <br /> JOB ADDRESS/LOCATION/Q /QI ���?�►`tr CENSUS TRACT - <br /> Phone <br /> Owner's Name <br /> / c City �TC1� <br /> Address ! <br /> Gontractcar's Name License 4� �Phone <br /> R4 <br /> TYPE OF WORK (Check): NEW WELL 'X DEEPEN/-7 RECONDITION /` / DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR '/ / PUMP'REPLACEMENT /-7 <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY j <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 Wit' <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel. Pack Depth of Grout Seal � <br /> Other Rotary Type of Grout D � <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. C Q <br /> PUMP REPLACEMENT: { / .,State Work Done <br /> PUMP 'REPAIR: / / State Work Done <br /> DF-,TRUCTION 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 Joaquin Local -Health District a <br /> WELL DRILLERS REPORT of the well. and notify them be€ore putting the well in use. The above <br /> information is trueto the best of my knowledge and belief. <br /> � - ....._ TITLE . .A <br /> SIGNED -- <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> j FOR DEPARTMENT USE ONLY " <br /> PHASE I <br /> 4 APPLICATION ACCEPTED .BY /[ � DATE. D`� <br /> ' ADDITIONAL COMI'MENTS: ^ <br /> PHAS I GROUT INSPECTION PHASE III/FINAL' INSPECTION <br /> k <br /> INSPECTION BY DATE -2/72 - INSPECTION .By DATE <br /> -CALL FOR A G U SPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> + V V 9/.1)A i <br />