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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFIC USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMITEXPIRES 1 YEAR FROM. DATE. ISSUED Date Issued X:6-�r3 <br /> (Complete In Triplicate) <br /> h 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 ofp the San J aquin Local Health District. <br /> i �'�oG![ K /CI" crr �7cr <br /> JOB ADDRESS/LOCATION V2:9- j <br /> CENSUS TRACT <br /> Owner's Name <br /> S. T GG C-7-OLE PhoneL�� - 70al. <br /> Address (} A/, f <br /> _ City Off/ <br /> Contractor's Name I/ <br /> License # 66Gz Phone W2-YJ � <br /> o <br /> TYPE OF WORK (Check): NEW WELL DEEPEN /-7 RECONDITION /-7 DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /? <br /> Other F/ / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY ' S <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER N <br /> NTENDED USETYPE OF WELL <br /> P CONSTRUCTION SPECIFICATIONS <br /> ustria o�,...,w�y�,.,�� Cable Tool Dia. of Well Excavation <br /> Domestic/ rivate Drilled Dia. of Well Casing <br /> Domestic/public _ Driven " Gauge of Casing <br /> Irrigation �: ' Gravel Pack Depth of Grout Seal <br /> Other _ Rotary A .Type of Grout L <br /> ^� <br /> r Other Other Information <br /> x i <br /> PUMP INSTALLATION: Contractor <br /> r <br /> Type of Pump ° <br /> PUMP REPLACEMENT: / / State Work Done ; <br /> PUMP REPAIR: ` / / State Work Done _ <br /> } <br /> ESTRUCTION OF WELL: Well Diameter <br /> - Describe Material and Procedure Approximate ,Depth_ <br /> I hereby agree to comply with all laws and regulations of the SankJoaquin Local Health District <br /> and the State of California pertaining to or regulating will construction. ' Within FIFTEEN DAYS <br /> after completion of my worst on' a new we'-l1—,-I--will' furnish the San Joaquin Local' Health_District a <br /> WELL DRILLERS REPORT of the well and notify them before putting the wellin 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 /> PHASE I FOR DEPARTMENT USE ONLY <br /> _. <br /> APPLICATION ACCEPTED BY TE <br /> ADDITIONAL COMMENTS: , <br /> TRAS "PEldtION- <br /> PHAWAIVWINALINSPECTION <br /> INSPECTION BY r ATE INSPECTION BY D <br /> CALL FORA IN ECTION PR OR GROUTING AND FINAL INSP I , <br /> L H 1426 7/72 1M <br />