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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> I FOR OFFUES;� 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6.781. `' <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit-No. <br /> q <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued (2---7-3 <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 Joaquin` <br /> Count Ordinance No. 1862 and the Rules and Regulations ®fdt e SanJoaquin Local Health District. <br /> r <br /> i <br /> JOB ADDRESS/LOCATION ro-,ode a i 0 -4 md. R CENSUS TRACT <br /> Owner's Named d m Phone <br /> Address <br /> Qi '`� Mrd � 1 City . <br /> Contractor's Name <br /> License # H37),4 Phone <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN / / RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR PUMP REPLACEMENT /_ <br /> Other / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <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 /> Grout Seal o <br /> Gravel Pack Depth f " <br /> Irrigation '`• s <br /> Other Rotary Type of Grout <br /> -Other Other Information ¢ <br />. PUMP INSTALLATION: Contractor -} <br /> Type of Pump H.P. . <br /> PUMP REPLACEMENT: 17 State Work Done <br /> PUMP REPAIR: State Work Done 1 � ,. ar I <br /> pESTRUCTION. OF WELL:' Well Diameter Approximate' Depth <br /> Describe Material and Procedure ?t: ' <br /> I hereby :agree to comply with all laws and regulations of the San Joaquin Local: Health •District i <br /> and the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> I will furnish the San Joaquin Local Health District a <br /> after completion.of my work on a new well, <br />•WELL DRILLERS REPORT of the well and notify them before putting the wellqn use. The above <br /> information is true to the best of my know ed <br /> SIGNEDTLE ,`> /' <br /> D PLOT PLAN ON RE SE SIDE <br /> FOR DEPARTMENT USE-ONLY <br /> PHASE I -- <br /> APPLICATION ACCEPTEDBY DATE - - ��7? <br /> . <br /> ADDITIONAL COMMENTS <br /> PHASE Ik\GRPkJT .INSPECTION PHASE III/FINAL INSPECTIO <br /> INSPECTION BY DATE, INSPECTION BY f DATE <br /> CALL FOR A GROUT INS ECTION PRIOR TO GROUTING AND',rAINAL INSP ON. <br /> E H 1426 7/72 1M: '� <br />