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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 permit No. ��- /4I3 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Date Issued <br /> (Complete In Triplicate) permit to construct <br /> Appleion is hereby made to 'the San <br /> daquTiisoLcal Health application istmade inrcompliance withSan Joaquin <br /> and /or install the work herein described, <br /> County Ordinance No. 1862 andlthe Rules and Regulations of the San Joaquin LocalHealth <br /> CENSUS TRACT <br /> JOB ADDRESS/LOCATION <br /> Phone <br /> i Owner's Name <br /> City �� �^rn tet c7' <br /> Address —� D <br /> -- License # r�'Phone ' <br /> Contractor's Name <br /> TYPE OF WORK (Check) : NEW WELL / I DE _ r7 DESTRUCTION /� <br /> EPEN /_7 RECONDITION / -T <br /> PUMP INSTALLATION / / PUMP REPAIR OQ PUMP REPLACEMENT I <br /> ! Other <br /> SEWER'LINES PIT PRIVY -- � <br /> DISTANCE TO NEAREST: SEPTIC TANK° CESSPOOL/SEEPAGE PIT OTHER r4. <br /> i SEWAGE DISPOSAL FIELD .1 <br /> ( ' CONSTRUCTION SPECIFICATIONS <br /> ! INTENDED USE .TYPE OF WELL <br /> _ Industrial j Cable Tool Dia. of Well Excavation <br /> Drilled Dia. of Well Casing <br /> Domestic/private Driven Gauge of Casing <br /> Domestic/public Depth <br /> of Grout Seal <br /> Irrigation Gravel Pack P <br /> } Other _� Rotary Type of Grout <br /> Other <br /> Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> PUMe REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / State Work Done <br /> Approximate Depth <br /> ESTRUCTION OF WELL: Well <br /> Material and Procedure <br /> I hereby agree to comply -with all laws and regulations of the San Joaquin Local Health District <br /> ll <br /> in FIFT <br /> and the State of California on a new well or regulating I will furnishethecSantJoaquin•L calhHealth Ds tDriet <br /> after completion of my work on a new , <br /> WELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> 1` information is true to the best of my knowledge and lief <br /> f � 4 <br /> k SIGNED �',{ W PLOT LAN 0 REVERSE SI ' <br /> FOR D ARTMENT USE ONLY <br /> PHASE I DATE 1� <br /> APPLICATION ACCEPTED BY <br /> ' ADDITIONAL COMMENTS: p II F <br /> IINAL INSPECTIO <br /> PHASE II GROUT INSPECTION INSPECTION BY DATE <br /> INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING. AND .FINAL INSPECT ON. 7/72 IM <br /> f E H 1426 <br />