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F FOR OFFICE USE: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> O •1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7Z,F 5� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> fl:0l G�: _y Date Issued <br /> Application hereby rmadhe San tJoaqufrteIn Local Health Triplicate) <br /> and/or install the work herein described. This application Distmade inrict compliance <br /> a pe pith construct <br /> County Ordinance No. 1862 ani the Rules and Regulations of the compliance with Ban Joaquin <br /> t <br /> San Joaquin Local Health District. <br /> ,. <br /> JOB ADDRESS/L AT ON -L ` <br /> Owner's N CENSUS TRACT <br /> _ 0 <br /> Addres Phone _9'U _ <br /> City <br /> Contractor's Name S <br /> f�R <br /> License <br /> # / 4 Phone <br />- .TYPE�OF�WORK„(,Check) : NEW,WE� <br /> LL/-T�DEEPEN- /- /`,.RRCONDITIflN /?--DESTRUC-TfiON /�- _�-`---_--- <br /> PUMP INSTALLATION. / / PUMP REPAIR / PUMP REPLACEMENT /� <br /> f Other R/ / <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWERLINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT �\ <br /> i OTHER <br /> INTENDED USE TYPE OF WELL <br /> Industrial CONSTRUCTION SPECIFICATIONS ti <br /> Domestic/private . Cable Tool Dia. of Well Excavation -� C <br /> Domestic Drilled Dia. of Well Casing <br /> /public Driven Well <br /> of Casing 1�3 <br /> Irrigation 1 Gravel Pack <br /> Depth of Grout Seal <br /> Other <br /> ! Rotary Type of Grout <br /> Other Other Information <br /> a <br /> PUMP INSTALLATION: Contractor <br /> Type ofi Pump <br /> _ ( H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: State Work Done <br /> ESTRUCTION OF"WEI.Lr Well ff ameter'— ` -,.,.. _._ <br /> Dep <br /> Describe Material and ProcedureApproximate th <br /> ----•--�.— <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health Districtj <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 />[nformation is true to the best of my knowledge and belief. <br /> iIGNED <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br />'HASE I FOR DEPARTMENT USE ONLY } <br /> APPLICATION ACCEPTED BY <br /> JDDITIONAL COMMENTS: .DATE f <br /> P S ' �GRO �DATE <br /> PECTIO <br /> NSPECTION BYPHA FINAL INSPECTION <br /> 2 Z3 L7" INSPECTION BY } <br /> - _ ,.. DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECT` ►� "*:_, <br />`.E H 1426 <br /> }u :. I ' / 7/72 IM <br />