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1/ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 7 <br /> !IZ La 10 APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ')2--2 o P <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued .j,Z,,F, -7t, <br /> (Complete In Triplicate) <br /> Application is hre y 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 / / CENSUS TRACT <br /> Owner's Name Phone r� <br /> Address ,� /bt .S ct�-i�7` City <br /> Contractor's Name Guess° � `�T_ License #/4f��Phone 7k <br /> TYPE OF WORK (Check): NEW WELL, DEEPEN /-7 RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION 07PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK #;O SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD -�'�a. + 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 <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. Cr <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: /7 State Work Done <br /> ,pESTRUCTION 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 he well and notify them before putting the well in use. The above <br /> information is t to of my owledge and belief. <br /> SIGNED TITLE <br /> IP z (DRA LOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE Iv <br /> APPLICATION ACCEPTED BY DATE L <br /> ADDITIONAL COMMENT <br /> PHA , PE FININSPECTION <br /> INSPECTION BY DATE <br /> INSPECTION BY ATE <br /> CALL FOR 'INOCECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 4/72 1M co, <br />