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d <br /> FOR <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT 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 1 YEAR FROM DATE ISSUED <br /> Date Issued, <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 Joaquin <br /> County Ordinance No. 1862 and the Rules d Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION <br /> CENSUS TRACT <br /> Owner's Name 14, ;; � � <br /> Phone <br /> Address <br /> Citi ,�,ra <br /> Contractor's Name <br /> License Phone263�S/ <br /> TYPE.-OF WORK .{:Check)_:. m.NEW�WELL�. �T. <br /> DEEPEN -,.R-EGONI)I^T-I-0Nti-/�„;2�-DESTRUCTI-ON--/-47-- <br /> PUMP INSTALLATION / MP REPAIR <br /> Other PUMP REPLACEMENT /7 <br /> / /� 'r -- <br /> DISTANCE TO NEAREST: SEPTIC TANK EWER L NES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD <br /> CESSPOOL/SEEPAGE PITS OTHER <br /> INTENDED USE TYPE OF WELL <br /> Industrial CONSTRUCTION SPECIFICATIONS p� <br /> Cable ,Toal, Dia. of We11 Excavation 'C <br /> ffTamestic/private Drilled. _.' Dia. of Well Casing <br /> Domestic/public Driven y Gauge of Casting <br /> Irrigation Graved Pack + Depth of Grout 1 <br /> Other <br /> --- __J=��tary N , Type of Grant <br /> 'Other Other Information <br /> PUMP INSTALLATION; <br /> Contractor <br /> - '" Type of Pump ' H.P. 9 <br /> PUMP REPLACEMENT. —- <br /> / / State Work Done <br /> PUMP REPAIR: / / State`Work Done <br /> DESTRUCTION OF WELL: Well Diameter <br /> ^i Describe Material and Procedure Approximate Depth .� <br /> I hereby agree to comply with all- laws and regulations of the San Joaquin Local Health Districts; j <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 Sam,Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the'weil and notify them-bofore 'putting 'the, well in use. The above y <br /> infor ation is, true to the be of nowledge and belief. <br /> SIGNED - r <br /> TITLE { <br /> W PLOT PLAN ON REVERSE SIDE <br /> FOR DEPART NT USE ONLY <br />'HAS � # <br /> IPPLICATION ACCEPTED BY ? DATE <br /> LDDITIONAL COMMENTS: <br /> PHASE iI 0 PHASE III FINAL INSPECTIO <br /> NSPECTION BY D INSPECTION BY <br /> DATE �a <br /> CALL FOR A GROUT SPECTION PRIOR TO GROUTING AND FINALINSPECTION. <br /> E H 1426 7/72 1M <br /> # . . <br />