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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE-OF'F'IH USE: 'V/1601 E. Hazelton Ave. ; Stockton, Calif.' j <br /> Telephone: (209). 466-6781 3 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <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 /> axed/or install the work herein described. , This application is made in compliance with San Joaquin; <br /> County Ordinance Na. -1862 and the Rules and Regulations of the San Joaquin Local Ilealth District. <br /> JOB ADDRESS/LOCATION ® $' .t CENSUS TRACT <br /> e <br /> f <br /> Owner's Name . „ . Phone 1 <br /> Address � ._ `�_ I-' ,l�/ " - � ,..,.,...,...-- ..:,,... .,.:_._ City , <br /> Contractors Name ! 6- License #. : "" '" Phone <br /> TYPE OF WORK, (Check) : NEW WELL 1W DEEPEN ./7 RECONDITION f-1 DESTRUCTION /-7 <br /> PUIMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT (7 <br /> Other / / <br /> DISTANCE TO NE IST SEPTIC TAi�1K SEWER LINES PIT PRIVY <br /> tic-5- SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> ,edustrial Cable Tool Dia`. of Well Excavation <br /> Domestic/private Drilled Dia. of Well- Casing <br /> Domestic/public Driven 1Gauge of Casing <br /> '-"7i -;.*-41rrigation ;,Gravel Pack Vopth of Grout Seal <br /> Other -- Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor , NNIN -s EROS <br /> Type .of Pump H.P. <br /> PUMP REPLACEMENT: / f State Work Done <br /> PUMP 'REPAIR: /—/-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 /> and the. State of California pertaining to or regulating 4ell"construction. Within FIFTEEN DAYS <br /> after completion of my work on a new ioell, 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 /> information is true to the best of my�.knowledge and belief. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ONREVERSESIDE) <br /> R DEPARTMENT USE ONLY <br /> PHASE I r <br /> APPLICATION ACCEPTSFIE= ATE r <br /> x ADDITIONAL Cole <br /> P ROUT INSPECTION P 891,I4/4&a INSPECT ! <br /> INSPECTIO DATED-2�-� INSPEC DATE ; <br /> CALL, FOR A GROUT INSPECTION PRIOR TO GROUTING D NAL N IONS 3 <br /> E x 1426. .. ..._ :" ._ {�' :': /�� � ' 5/73�.M <br /> - -- <br />