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N <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> =OF.' O1 FI_C USE: 1.601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ?/74. <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 Joaqu3 <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District <br /> JOB ADDRESSILOCATION /1 ^� CENSUS TRACT 'Q0 4 <br /> Owner's ►varve Phone - <br /> Address (. � 9;9 - City , 1 <br /> Contractor's Name_ u L License {��s�lD Phoned--Qli <br /> a <br /> TYPE OF WORK (Check): NEW WELL /� DEEPEN '/ / RECONDITION,::/ { DESTRUCTION /rT <br /> PUMP INSTALLATION / PUMP REPAIR'/ / PUMP REPLACEMENT FT , <br /> Other ./ / M <br /> DISTANCE TO NEAREST: SEPTIC TAN WER LNES T PRIVY <br /> SEWAGE DISP SAL FIELD�� ESSPOOL/SEEPAGE PIT,�(,j � OTHER �� 6 <br /> INTENDED USE TYPE OF WELL .CONSTRUCTION SPECIFICATIONS c <br /> In atrial Cable Tool Dia. of Well Excavation D <br /> omestic/private Drilled Dia. of Well -Casing I <br /> Domestic/Public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Se <br /> Other Mary Type of Grout 17 <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor L <br /> Type of Pump <br /> PUMP REPLACEMENT: State Work.bone " <br /> PUMP UPAIR: State Work Done ° <br /> _ <br /> ,DESTRUCTION OF WELL: Well Diameter Approximate" De Pth <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 /> j. WELL DRILLERS REPORT of the.well and notify ,them before putting the well in use. The above <br /> infor ation is true to the be nowledge and belief. sf <br /> t SIGNED TITLES—d caI <br /> (DMW PLOT PLAN ON REVERSE SIDE <br /> r FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED .BY ��� DATE ��}` 7 <br /> ADDITIONAL COMMENTS: <br /> P E II, GROUT. INSPECTION - - - -- P E I /FINAL INSPECTION <br /> ' INSPECTION EY1` . ` ' C a_ DATE INSPECTION B DATE 3---r- 7 <br />