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n / <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT O ply <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton Calif. <br /> Telephone: (204) 466-6781 <br /> /jIAPPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 3 snip <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued $ J3 <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 /> JO$ ADDRESS/LOCATION. REY C ARECENSUS TRACT <br /> Owner's Name <br /> Phone y <br /> Address 24 p ;' a <br /> I f <br /> City S d v <br /> contractor's Name J f License jf4R.�o Phone <br /> TYPE OF WORK (Check): NEW WELL /_7 DEEPEN /7 RECONDITION /-7 DESTRUCTION /_7 <br /> PUMP INSTALLATION Ik" PUMP REPAIR /—/ PUMP REPLACEMENT / <br /> Other j/ <br /> DISTANCE TO NEAREST: SEPTIC*TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL <br /> CONSTRUCTION SPECIFICATIONS <br /> In .. <br /> dustrial Cable Tool Dia. of -Well Excavation IO <br /> Domestic/private Drilled Dia. ofWellCasing .� <br /> Domestic/public Driven Gauge' of• Ca-siiig 4_ <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> I PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> H.P. / <br /> PUMP REPLACEMENT: /if' State Work Done <br /> �- PLS-REPAIRo r. _ —/ Stare Work-Doris <br /> ,1DESTRUCTION OF WELL:Z' Well Diameter i <br /> Describe Material and Procedure Approximate Depth <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 <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> f WELL DRILLERS REPORT of .the well and notify them before putting the well in use. The above <br /> information is t ue to the. best of my knowledge and belief. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> i <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I �y <br /> APPLICATION ACCEPTED BY Cy� DATE a p <br /> ADDITIONAL COMMENTS: <br /> PHASE II OUT INSPECTION P AL INSPECTION <br /> INSPECTION BY DATE INSP ON B DATE <br /> CALL FOR A GROUT NSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 <br /> 7/7-2 1M <br />