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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> OFFICE USE: V 1601 E. Hazelton 'Ave.; Stockton, Calif. <br /> FOR 0 .. <br /> Telephone: (209)- 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION 'OR PUMP PERMIT Permit No. 13-2-50 <br /> THIS PERMIT 'EXPIRES 1 YEAR FROM DATE ISSUED Date Issued. 3 7 3 <br /> �# (Complete In Triplicate) <br /> Application is hereby made- to'ithe San Joaquin. Local Health District for a permit to construct <br /> and/or install the work herein described. This applidatioa 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 -L? CENSUS 'TRACT' <br /> �= t h c <br /> Owner's Name ��t6_ $hone <br /> Address City <br /> v License ����,PhoneK2.3,6r, <br /> Contractors Name _. <br /> TYPE OF-WORK (Check)­.—NEW WELL '" DEEPEN" /?" 'RECONDITION/-7-AL -DESTRUCTION <br /> �/� <br /> PUMP INSTLATION / / PUMP REPAIR / J PUMP REPLACEMEI�T <br /> Other '/ — ••• <br /> J <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 �R <br /> Industrial i Cable Tool Dia, of Well Excavation ..t► <br /> 4 _ X 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 /> IANDO M <br /> 1 436WeLL To A�3 <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump (� H.P. <br /> PUMP REPLACEMENT: J J State Work Done a ' 7S' IA-0 <br /> F <br /> kPUMP REPAIR: i / / State Work Done <br /> j,PESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I' l 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 fu ' ish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notify them befor putting the well in use. The above <br /> information is true to the best of my knowledge and be ief. <br /> SIGNED L l• TITLE ' <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> OR MENT USE ONLY <br /> PHASE`,I y `* <br /> ATE <br /> ♦ APPLICATION ACCE BY <br /> ADDITIONAL CO <br /> OUT .INSPECT BI P II F AL INSPECTI <br /> INSPEC ATE INSPE <br /> CALL FOR A GROUT.INSPECTION..PRIOR TO GROUTING AND FINAL INSPECTION. <br /> TJ72 1M <br /> E H 1426 �✓'� <br /> k ~ <br />