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it <br /> W � 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. L� � <br /> THIS PERMIT EXPIRES i YEAR FROM DATE`ISSUEDf 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 Joaqui <br /> County Ordinance No. 1$62 and the Rules and Regulations of .,-the <br /> San /Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION <br /> G - CENSUS TRACT . <br /> p <br /> Owner's Name 62/1 -----•--- .,_.-- - - Phone � 3- <br /> Address �p City ,CjE- y� ,� <br /> Contractor's Name ,per,-L _ ����✓ �. License 4t :d&;32aPhone 2 <br /> E <br /> TYPE OF WORK (Check) . NEW WELL DEEPEN /-7 RECONDITION /-7 DESTRUCTION/-7 _ <br /> PUMP INSTALLATION /—/ PUMP REPAIR /—/ PUMP REPLACEMENT /-T <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY t <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� - <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation �- Gravel Pack Depth of Grout Seal's <br /> Other 1,/ Type of Grout <br /> Other Other Information <br /> 4-. <br /> PUMP INSTALLATION: Contractor <br /> - -- Type of Pump ti H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP-_REP6IR: 177/ State. Work Done - - <br /> ,pESTRUCTION OF WELL: Wel] Diameter - <br /> _ -- Approximate Depth <br /> Describe Material and Procedure - <br /> .I 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 /> F 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 knowledge and belief. <br /> SIGNED TITLE <br /> (WAW PLOT PLAN ON REVERSE SIDE <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> - - • _- - I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: M <br /> P E I , &TPhN P E I r INAL INSPECT;,ON <br /> cINSPECTION BYDXTE / INSPECTION BY ' Apr I DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. II <br /> E .H 1426 7/72 IM <br />