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D ' l SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton• Ave', , Stockton, Calif. <br /> Telephone:: (209) 466-6781 <br /> APPLICATION FOR WELL 'CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT-EXPIRES l' YEAR FROM DATE ISSUED Date Issued, <br /> (Complete In Triplicate) <br /> Application is-hereby made>tolthe ''San Joaquin Local Health District for a permit to construct <br /> and/or install the work hereixi described. This application is made in compliance with San Joaquin- <br /> County Ordinance .No 1862•-addithe Rules and Regulations of the San Joaquin Local Health District, <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's"Name ' a ' A : �CJt/,_ Phone <br /> Address City (" <br /> Contractor's Name 84- License fig 0 �, Phone <br /> TYPE OF WORK (Check) : ;rNEW�WELL / �DEE_PEN /� RECONDITION /_7 DESTRUCTION /_7 <br /> ;PUMP INSTALLATION / UMP REPAIR / / PUMP REPLACEMENT /-J <br /> Other---,/. / <br /> €1ISTANCE TO NEAREST: SEPTIC TANK SEWER LINES p f-PIT PRIVY <br /> SEWAGE DISPOSAL .FIELD �`�� -f---CESSPOOL/SEEPAGE PITS OTHER <br /> � l. <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Ind atrial Cable Tool Dia, of Well Excavation <br /> omestic/private` Drilled Dia. of Well Casing \ <br /> Domestic/publicDriven Gauge of Casing Q b' <br /> Irrigation.rt i A Gravel Pack Depth of Grout Seal �--- <br /> Other, Mary Type of Grout — ,M <br /> Other Other Information <br /> PUMP .0INSTALLATION: - Contractor �. <br /> i,T- pe o f Pump - H..P. �--l•�=,� <br /> PUMP REPLACEMENT: �„f *f <br /> State Work�Done � <br /> PUMPREPALR-:-�. '. �-/ 'S,pa�te Work Done ��. Yv j <br /> jDESTRUCTION OF WELL: Well Diameter <br /> - - _ Approximate Depth <br /> .Describe Material and Procedure <br /> I hereby agree to comply with a'li laws and-regulations of the_5an Joaquin Local Health*District <br /> and the State of California pertaining to or regulating well-const-ruction. 4w-ithin- 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 notify them before putting the well in use. The above <br /> inform ion is true to the es of knowledge and belief. <br /> SIGNED TITLE p t� <br /> W PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> DITIONAL COMMENTS: - <br /> PHA I T 1N9 E y -"P 'S IT AL INSPECTION <br />*SPECTION BYE ":DATE. INSPECT DATE 17, <br /> T . 340- <br /> "CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. - <br /> E H 1426 _ f n; �. 7/72 IM �2 <br /> . . i <br />