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SAN JOAQUIN LOCAL HEALTH DISTRICT <br />' IOx.;OFf'lLUSE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> % Telephone: (209) 466-6781 <br /> I APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ��/-.� <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 /> f ' <br /> JOB ADDRESS/LOCATION . CENSUS TRACT , <br /> Owner's Name - 13 2-fA ,/ — - V/GC- Phone SSGi.-6-9 / <br /> Address City ' " `—G1 c/T- Z4 <br /> - <br /> Contractor's .Name J License Phone : ,Z <br /> TYPE OF WORK (Check): NEW-WELL'-/ / DEEPEN '/-/ RECONDITION /—/ DESTRUCTION /7 <br /> PUMP-INSTALLATION J / PLMP REPAIR / / PUMP REPLACEMENT /? <br /> - Other <br /> DI.STANCE,TO,NEAREST: SEPTIC TANK2,PI SEWER LINES PIT PRIVY <br /> 'p I—SEWAGE,DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE , tip s.-.. TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial V Cable Tool Dia. of Well Excavation IN <br /> Domestic/private " 7N Drilled Dia. of Well Casing <br /> Domestic/publicDriven 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. <br /> ffi <br />' PUMP REPLACEMENT: / / State Work Done <br /> i <br /> PUMP, UPAIR: / / State'iiork Done <br /> ,DF<TRUCTION OF�WELL: Well I)iaiiiete �'`'� '�" Approximate, Death <br /> Describe Material and Procedure <br /> I hereby agree eta comply with all Taws and regulations of the San Joaquin Local Health District <br /> f and the State-of;rCalifornia. 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 theni before putting the well in use. The above <br /> info_r-ma tion is true- the.bests-df,mV-kn-owledge jand belief. i <br />� R <br />'i SIGNED TITLE n <br />{ (DRAW PLOT PLAN ON REVERSE SIDE) _.. <br /> a <br /> FOR.-DEPARTMENT USE ONLY p <br /> .F PHASE I r �•-� `i ,,,,.:,.,..,:... � � t <br /> 3 APPLICATION..-ACCEPTED .BY r _ <br /> r. .. DATE, <br /> AD Q NAL COMMENTS: <br /> SWA�PECTI E I ROUT A E 'Er �r I J AL INSPECTION <br /> SPEC I DATE <br /> CALL FOR A. GROUTp4 SPECTIf !"P GROUTYC-kN <br /> E .H 1426 // /// 5/71im <br />