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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.Za--Arm.�'!J <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 /> JOB ADDRESS/LOCATION D�� ,� b CENSUS TRACT <br /> Owner's Name _4/) e!9,&_<7�-1. - Phone <br /> Address City �� p <br /> Contractor's Name A License IV20 Z )f7hone w _ 1 <br /> TYPE OF WORK (Check) : NEW WELL /7,?�DEEPEN /—/ RECONDITION /_7 DESTRUCTION /7 <br /> PUMP INSTALLATION J / PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPO FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE, ' TYPE OF ELL CONSTRUCTION SPECIFICATIONS <br /> industrial Cable Tool Dia. of Well Excavation <br /> C/ Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing �I <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout tel" <br /> Other Other Inf ormat4on <br /> PUMP INSTALLATION: Contractor 2re 142-9 y <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br />,DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure i <br /> i <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 k <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 abode <br /> information is true to the best of my knowledge and belief. <br /> SIGNED } <br /> TITLE <br /> {D PLOT PLAN ON REVERSE SIDE <br /> DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE ` <br /> ADDITIONAL COMMENTS: ' <br /> PHAS T1 PHAWI /F AL INSPECTION <br /> INSPECTION BY0=14 D T ,�/l z z _yv�_ INSPECTION BY DATE v <br /> CALL FOR A NSPEC ION PRIOR TO GROUTING AND FINAL IN I <br /> E H 1426 7/72 1M <br />