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',�;�•� SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton 'Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ;%�-lo 3 4l <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 3-/-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 Joaqui: <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name :' / Phone --� <br /> Address ° / '" L� - 1 city <br /> Contractor's Name • ` License # Phone <br /> --CI(7- <br /> TYPE <br /> TYPE OF WORK (Check) : NEW WELL / : DEEPEN /_/ RECONDITION /_7 DESTRUCTION <br /> AL <br /> PUMP INSTLATION PUMP REPAIR / / PUMP REPLACEMENT /0 _ <br /> .Other /_7 — <br /> ( DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> L <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER. }� <br /> f .. � rk � <br /> INTENDED USE TYPE OF WELL / CONSTRUCTION SPECIFIC TIONS <br /> Industrial Cable ToolDia. of Well Excavation <br /> Domestic/private' Drilled Dia, of, Well Casing ' ' <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout,Seal- 7IN <br /> Other Rotary Type of+Grout <br /> Other Other Information <br /> f <br /> s G� <br /> PUMP: INSTALLATION: � Contractar� <br /> Type of "pump 67 H.P. <br /> } jox <br /> PUMP REPLACEMENT: State Work Done <br /> i — <br /> PUMP REPAIR: / / State Work Done <br /> ,DESTRUCTION OF WELL: , Well Diameter Approximate Depth <br /> Describe 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 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 <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BYDATE / <br /> ADDITIONAL COMMENTS <br /> Y", <br /> r--'GI INSPECTION PHASE FINAL SPECT'ION <br /> INSPECTION BY DATE - -741 INSPECTION BY TE r <br /> CALL FOR A G �TT- TION PRIOR TO GRO TING AND FINAL INSPECTION. <br /> E H :1426 l 7/72 IM <br />