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r/ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit <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 <br /> County Ordinance No. 1862 and -the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION e�ry���,� CENSUS TRACT <br /> . i <br /> Owner's Name' . r 4 Phone <br /> Address S d,P Tee ni � City <br /> Contractor's Name 2 /'or,, S S�,E% License #/,/_Z373 Phone <br /> 0.117 y ah l na 3 S C Ci/,", t-rq <br /> I TYPE OF WORK (Check) : NEW WELL DEEPEN /—/ RECONDITION /_7 DESTRUCTION /� gs2zo <br /> PUMP INST LATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other / /. - <br />' DISTANCE TO NEAREST: SEPTIC TANK Z �" SEWER LINES 5`V PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial �)S- Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing t <br /> Domestic/public Driven Gauge of Casing _ <br /> Irrigation Gravel Pack Depth of Grout Sea <br /> i <br /> Other, , . Rotary Type of Grout G <br /> Other Other Information <br /> t <br /> PUMP INSTALLATION: Contractor W <br /> Type of rump 0 <br /> H.P. <br /> " e <br /> PUMP REPLACEMENT: / / State Work Done <br /> pVer <br /> PUMP REPAIR: State Work Done ( S / Lc/ rn <br /> 2ESTRUCTION 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 before putting the well in use. The above <br /> information is true to the best of my knowledag'e� and belief. <br /> SIGNED TITLE a '7 o)" i <br /> (DRAW PLO PLAN ON REVERSE SIDE <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> _ <br /> APPLICATION ACCEPTED BY r r, 3 <br /> DATE -51 <br /> ADDITIONAL COMMENTS- / � C ` /S /e P mar / L <br /> PHA T SPECTION III F NAL INS ECTION r <br /> INSPECTION BY DATE _ INSPECTION BY ATE <br /> CALL FOR SPECTION PRIOR TO GROUTING AND FINAL INSPECTIOC. <br /> E H 1426 <br /> 7/72 1M <br />