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SAN JOAQUIN LOCAL. HEALTH DISTRICT <br /> E <br /> 1601. <br /> . Hazelton Ave. , Stockton, Calif. <br /> "OFFICE USE: r <br /> ' Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued -7-2-6-77 <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 /> ftt k . �/ , CENSUS TRACT <br /> JOB ADDRESS/LOCATION Aj <br /> Owner's Name /� <br /> f C�.ty f•»-41�.2�-� <br /> Address . _ (.11� <br /> tfi ! LLicense # fl f Pie <br /> one ' `'E <br /> Contractor's Name i-�. ' 11�'. - �r !� <br /> TYPE OF WORK (Check) . NEW WELL/ DEEPEN / 1 RECONDITION_/ / DESTRUCTION IT - <br /> PUMP INSTTION I / PUNiR <br /> S' REPAIR / / PUMP <br /> REPLACEMENT /_7AT.CA- \` <br /> Other <br /> SEWER LINES PIT PRIVY cS�l46( ��j1•�rr1 <br /> ` DISTANCE TO NEAREST: SEPTIC TkNK. <br /> f SEWAGE DISPOSAL FIELDCESSPOOL/SEEPAGE PIT OTHER. t=/ ` <br /> INTENDED USE TYPE OF. WELL f ;_ CONSTRUCTION SPECIFICATIONS - <br /> Industrial �.�Cabie Tool Dia`o' o.f,.WellrExcav_a on � , <br /> ,,-Pomestic/private Drilled Dia. ,of'Well-Casing _ <br /> Driven Gauge.,of Casing ` <br /> Domestic/public <br /> Irrigation Gravel Pack Depthi�of�Grout Seal <br /> i Other Rotary Type-ofy,-Orout <br /> -�--� Other:< _ Other Information <br /> If <br /> PUPJP INSTALLATION; Contractor i <br /> TyP o ump <br /> - E <br /> PUMP REPLACEMENT: /_7 State Work Done <br /> PUMP `tEPAIR: / / State Work Done <br /> DFsTRUCTION 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 /> y and the State of California pertaining to or regulating well ''construction. Within FIFTEEN DAYS <br /> t <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health Dover ct <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 /> TITLE <br /> SIGNED / (DRAW. PLOT-PLAN. .ON REVERSE. SIDE},. . <br /> FOR DEPARTMENT USE ONLY <br /> PHASE LATE <br /> D <br /> M, APPLICATION ACCEPTEb•'.BY' <br /> x <br /> ADDITIONAL,. COPHASESII GROUT iNSPECTiON' PHASE aII/FINAL INSPECTION' <br /> DATE. INSPECTION BY - ✓ TE s'��- � : <br /> DA <br /> INSPECTION BY <br /> GALL-.FOR;:A-;-GROU-T-INV pECTION=.PRI.OR--Tp-GROUTING AND FINAL INSPECTION.- 5/731M f731M <br /> ,T <br />