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M,S• ,. .F ':.._,,. �•. .,\-f•.. ,ti'..": E .+ i t.iM _ . - - fir`--"'���rtvr-� <br /> SAN JOAQUINYLOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. ,.'Stockton, Calif. <br /> Telephone: (209)466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR,PUMP PERMITPermit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) L)SS-(,?o - <br /> Application is hereby made to ;the San,Joaguin Local Health District for a permit to tonstruct' <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 Loca'1' Health District. <br /> ST Z& "�_770 .E <br /> OB-ADDRESS/LO ION <br /> CENSUS' TRACT ' <br /> Owner's Name <br /> Phone <br /> Address Cit i <br /> :. y <br /> Contractor's Name License �E <br /> pC_� Plion <br />--TYPE OF WORK- (Check): 'NEW-WELL DEEPEN... RECONDITION-/---7--DESTRUCTION/= <br /> PUMP INSTALLATION PUMP REPAIR' /—/ PUMP REPLACEMENT /_7 <br /> Other <br /> DISTANCE-TO NEAREST: SEPTIC TANK <br /> R LINES PIT PRIVY <br /> 1 ' SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> NTENDED USE TYPE OF WELL CONSTRUCTION SPECIFIC IONS <br /> Industrial able Tool Dia. of Well Excaion y <br /> Domestic/private Drilled Dia. of Well Casing: <br /> Domestic/public Driven Gauge of Casing �c <br /> rrigation Gravel Pack Depth of Grout Seal <br /> Other <br /> Rotary Type of Grout <br /> Other <br /> Other Information - <br /> t <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> 7' <br /> ESTRUCTION OF WELL: Well Diameter T -� <br /> Approximate Depth <br /> Describe Material and Procedure. .. <br /> T� - <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 -4 j <br /> WELL DRILLERS REPORT of the w and notify them before putting the we in use. The above <br /> information true t � the o my knowledge and belief. <br /> SIGNED <br /> TITLE <br /> (DRAW LO PLAN ON REVERSE SIDE <br /> FO DEPARTMENT USE ONLY <br /> PHASE I , <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PRASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE �3 <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />