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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> For OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 16 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ML^J N P <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -L 7 <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 Disprict. <br /> JOB ADDRESS/LOCATION ,` 33C w ` <br /> SS CENSUS TRACT 0Oz©-o 13 ` / <br /> Owner's Name ZZ_�2vaE' Phone <br /> Address 42S <br /> '70 City Cft' <br /> Contractor's Name License # Phone,36�- <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN /_/ RECONDITION / / DESTRUCTION /_7 <br /> PUMP INSTALLATION /3< PUMP REPAIR /—/ PUMP REPLACEMENT 17 <br /> Other Zzxf &A7wi h ! PT . <br /> - <br /> DISTANCE TO NEAREST: SEPTIC TANK 5EWER LINES PIT PRIVY � <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER o <br /> INTENDED USE TYPE OF WELL _ CONSTRUCTION SPECIFICATIONS <br /> Industrial � Cable Tool __D a. of Wel.1 Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of- Casing <br /> t.�-Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other-Information <br /> PUPT INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: State Work Done '.&_ &M <br /> PUMP `tEPAIR. / / State Work Done. <br /> .DFRTRUCTION OF WELL: Well Diameter Approximate Depth <br /> De-scribe Material and Procedure <br /> 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 /> after completion of my work on a new well, I will furnish the San Joaquin Local Health Distract 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/ ®,Q <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASEAPPLICATION <br /> I <br /> APPLICATION ACCEPTED BY DATE _66-:72- <br /> ADDITIONAL <br /> 6":72^ADDITIONAL CO]IMNTS: ai <br /> PHASE II GROUT INSPECTION -- - PHASE ITT/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 5/731M <br />