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f <br /> . c1 — <br /> SAN JOAQUIN LOCAL 1iTALTH DISTRICT <br /> FOR OFFICE USE: � 1601 E. Hazelton'Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> WPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7��� <br /> THIS PERMIT ,EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 6-,) y <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 worm 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 0 CENSUS TRACT <br /> Owner's Name -? Phone 's` _ <br /> Address �L � , - C? - uvt, CU • City p <br /> Contractor's Name-- E-) ML_L a-4i .._ License # Phone <br /> TYPE OF WORK (Check): NEW WELL . DEEPEN/% RECONDITION / 7 DESTRUCTION %T <br /> PUMP INST LILATION / / PUMP REPAIR / { PUMP REPLACEMENT / <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY J 5 <br /> SEWAGE DISP SAL FIELDS U D CESSPOOL/SEEPAGE P T OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS ' <br /> Industrial Cable Tool Dia. of Well Excavation O <br /> - Domestic/private Drilled_ Dia. of Well Casing & 6 <br /> iDomestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> .teaa—''--, <br /> PUMP INSTALLATION: Contractor [� 'qe? (� <br /> Type of Pump H.P. <br /> I PUMP REPLACEMENT: / r State Work Done zz <br /> PUMP REPAIR: _7 State Work Done <br /> DESTRUCTION OF WELL: Well Diameter �j 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 otif -them before putting the well in use. The above <br /> information is a to the best of kno edge and belief. <br /> SIGNED <br /> l.� TITLE 5'D v1. t <br /> I.DIMI; PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE V1 7, <br /> ADDITIONAL COMMENTS: <br /> PHASE 11 GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE -A .?_._ INSPECTION BY DATE -3 -?z- <br /> CALL <br /> 7zCALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. W <br /> E H 1426 4/72 1M <br />