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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> r'0�'..OFFICL USL: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781, `� '. <br /> ,APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7.3� <br /> T <br /> THISPERMITEXPIRES l YEAR FROM DATE ISSUED Date Issued /D i�1 3 <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 Jbaguin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> ✓ o � , d <br /> Owner's Name]/ '� /� �� <br /> k - <br /> E' <br /> Address /__j City��i T <br /> Contractor's Name' 7 /� � License , -:hone <br /> TYPE OF WORK (Check) NEW WELL DEEPEN '/—/ RECONDITION / ./„ DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PLW REPAIR / / PUMP REPLACEMENT 17 <br /> Other ./7 <br /> DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES _ PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> c <br /> INTENDED USE TYPE OF WELL, CONSTRUCTION SPECIF ATI S <br /> j <br /> Industrial Cable, Tool Dia.. of Well Excavation U <br /> Domestic/private Drilled Dia, of We11Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack - Depth of- Grout Seal <br /> Other Rotary Type of.Grout <br /> - Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: State Work Done <br /> t _ 1 <br /> PUMP 'tEPAIR: / S teu Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> aI hereby- agree to comply with all laws, and regulations of the San Joaquin Local Health District <br /> and the. State of California perta.ir;,irig to or regulating well construction. Within FIFTEEN DAYS <br /> after completion of my work`on anew I 'll, I will furnish the San Joaquin Local Health District <br /> WELL DRILLERS, iEPORT-of the. well and notify -them before putting the well in use. The above <br /> informat'- I"i's_'true :• <br /> to the best ofmyknowledge and belief. <br /> m <br /> i TITLE _ <br /> SIGNED_._. -- <br /> ti (DRAW PLAT PILOT-ON REVERSE .SIDE) <br /> FOR DEPARTMENT USE ONLY, <br /> PHASE I r� � 7 <br /> DATE !v 3 <br /> APPLICATION ACCEPTED .BY <br /> ADDITIONAL COlkMENTS: 3 <br /> 7 PHAS / INAL INSPECTION <br /> PHASE II GROUT IN $CTIOi� --- -- <br /> INSPECTION BY DATE 10_4f__71 -- INSPECTION BY DATE/leP- 714/• - — <br /> : CALL-FOR--A.GROUT' INSPEGTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> 5/731M <br />