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r SAN JOAQUIN LOCAL 17-FALT1I 'DISTRICT <br /> 0 <br /> OFFICE USE: 160.1 E. Hazelton Ave. , Stockton; , Calif. i <br /> Telephone: (201) 466--6781. � <br /> 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 j <br /> and/or install the work herein described. This application is made in compliance with Sah,,Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> .TOB ADDRESS/LOCATIONs� <br /> � CENSUS TRACT <br /> Owner's Name ��,,e2 Phone <br /> Fj <br /> Address56- City <br /> Contractor's Name License # Phonemca <br /> +0 <br /> TYPE OF WORK (Check) t NEW WELL DEEPEN RECONDITION RECONDITION /? DESTRUCTION /7 <br /> PUMP INSTALLATION / I PUMP REPAIR / / PUMP REPLACEMENT <br /> Other O` <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 ZAT 'rti <br /> Domestic/private Drilled Dia. of Well Casing , <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> OtherRotary Type of Grout - <br /> Other Other Information ' S&-Iwot <br /> PUMP' INSTALLATION: Contractor CZ 3 !i <br /> Type of Pump.- H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: /% State Work Done <br /> ,DESTRUCTION OF WELL: Wel Diameter � A proxima e e th <br /> Describe Material and Procedure p fl <br /> `�. <br /> �I <br /> I hereby agree to comply with all laws and regulations of the San quin Local Health District <br /> RnA the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS j <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 them before putting the well in use. The above <br /> information is true to the best of my knowledge and belief. <br /> SIGNED TITLE 1 <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I � ' � <br /> APPLICATION ACCEPTED BY Ifs a 1�.lEp DATE �� 173„ , . <br /> ADDITIONAL COMMENTS: <br /> P INSPECTIO PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE q ' <br /> CALL FOR6� S <br /> PECTION IOR 7 ROUTING AND FINAL INSP ON. <br /> E H 1426 4/72 1M <br />