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y/ Q V 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. ,3- Z�9 <br /> THIS PERMIT EXPIRES 1 YEAR FROM.DATE ISSUED Date Issued , K3 <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 Joaqui <br /> County Ordinance No. .1862- and the Ruler. <br /> and <br /> . Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 4:55� A��� ��11-n �i� CENSUS TRACT ` <br /> Owner's Name Y!) Phone ,6,Q '2 7 <br /> Address City 4S7� <br /> ' �� St1�// (!.�/ ���yi/ License # g�1s2 Phone,5 <br /> Contractor s Name _ , <br /> TYPE OF WORK (Check) : NEW WELL '/-7 DEEPEN /y / RECONDITION /_� DESTRUCTION <br /> PUMP INSTALLATION /-PUMP REPAIR / / PUMP REPLACEMENT /� <br /> AL <br /> Other, /7/ =� — <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE -DISPOSAL FIELD T .-- ,CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Toole - Dia. of -Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing r: <br /> R v <br /> Irrigation Gravel Pack' Depth 'of Grout Seal-'- <br /> Other <br /> eal'Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor , <br /> Type'of Pump , H.P. f <br /> PUMP REPLACEMENT- / / State Work Done <br /> ,..PUMP_REPAIR:. <br /> ��State-v, -Done_f <br /> _- ,---/Y/ <br /> t / � <br /> ,pESTRUCTION OF WELL: Well Diameter Approximate Depth � <br /> [�— <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 <br /> WELL DRILLERS REPORT of •thewell and notify them before putting the well in use. The above <br /> ! information is true to the best of my knowledge and belief. <br /> SIGNED <br /> k TITLE <br /> f (DRAW PLOT PLAN ON REVERSE SIDE <br /> * FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEP BY DATE �-� �� <br /> ADDITIONAL CO <br /> P I G INSPECTION P II AL INSPEC N �� <br /> INSPECTI N ATE INSPE ON BY DATE <br /> CALL FOR A. GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426; 7/72 1M <br />