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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F'OF. OF ICL i}SE: 1b01 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> Zy- 37 �J <br /> THIS PERMIT EXPIRES YEAR FROM DATE ISSUED 71f- 3�/° <br /> • Date Issued _Z_2 .]c <br /> Application is hereby wade to the San EJoaquin Local Health District fora permit <br /> t <br /> and/or install the work herein described. - This application is made in compliance withnSan JOaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION <br /> v IG,G CENSUS TRACT ' <br /> Owner's Name ��/ <br /> Phone <br /> Address L�l� G 1 <br /> • City <br /> II, jo <br /> Contractor's Name <br /> C License Phone <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN <br /> /—/ RECONDITION / / DESTRUCTION /� r <br /> PUMP INSTALLATION „D< PUMP REPAIR / / PUMP REPLACEMENT /- <br /> Other /% <br /> DISTANCE TO NEAREST: TIC TANK <br /> SEWER LINES PIT PRIVY f <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT <br /> OTHER <br /> INTENDED USE TYPE OF WELL <br /> Industrial CONSTRUCTION SPECIFICATIONS <br /> Cable Tool, Dia. of Well Excavation �F <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven <br /> Irrigation Gauge of Casing <br /> Gravel Pack Depth of Grout Seal d <br /> Other Rotary Type of Grout +,. . <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> C <br /> Type of Pump <br /> _ H.P. <br /> PUMP REPLACEMENT. // State Work Done <br /> �t <br /> PUMP 'tE1'AIRs State Work Done <br /> ,DF-qTRUCTION OF WELL: Well Diameter i <br /> Describe Material and Procedure Approximate Depth <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 F'IF'TEEN DAYS <br /> after completion of my work on a new well, I will <br /> WELL DRILLERS REPO furnish the San Joaquin Local Health District a <br /> information the well and notify them before putting the well in usea est o my oVledge and belief. . The above <br /> SIGNED . <br /> 51 <br /> TITLE <br /> W' (DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE I EPARTMENT USE ONLY <br /> APPLICATION ACCEPTED B �� <br /> ADDITIONAL CO:=NTS• DATE <br /> P OU INSPECTION PHASE FIN INSPECTION <br /> INSPECTION BY / DATE INSPECTION BY <br /> DATE <br /> CALL FOR A.: � <br /> E H 14 C ON PR OR TO GRO ING AND FINAL INSPECTION. <br /> 2�,G/''- <br />