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2L-'::Z <br /> VVV SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE E: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 3rz.,�8 w <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 Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations� of the San Joaquin Local Health District. <br /> CT-- <br /> JOB ADDRESS/LQCATION CT- <br /> a CENSUS TRACT Sr S <br /> t f i <br /> Owner's Name Phone <br /> Address <br /> tI�WG� City <br /> Contractor's Name Ply License #&Z� Phone .. l <br /> TYPE OF WORK (Check) : NEW WELL /7 DEEPEN /_/ RECONDITION /7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other -/-/ PA D <br /> DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS Q' <br /> _ Industrial Cable Tool Dia. of Well Excavation <br /> 4 Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> 1l' <br /> PUMP INSTALLATION. Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: /% State Work Done <br /> E,p STRUCTION 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 />, in€ormation is true. to the best of my knowledge and belief. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) _ <br /> FO DEP T USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPT ATE ,lj - �Z/- <br /> ADDITIONAL CO " <br /> P OUT INSPECTION P I AL INSPECTION <br /> INSPECTION DATE5--,72-77 INSPEC ON By <br /> CALL FOR A GROUT INSPECTION PRIOR. TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />