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' 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. /7 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued2-,2,7-2-7 <br /> (Complete In Triplicate) <br /> Application is hereby spade 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 Ru'lejs and. Regulations C the San Joaquin Local Health District. <br /> ,TOB ADDRESS/LOCATION �a7Y `0IAi"m 6t CENSUS TRACT <br /> _F <br /> �1 l/ R <br /> Owner's Naive Phone ' <br /> .. a��h_r'� - --- --- <br /> Address 96 2 ` City S,-740� <br /> Contractor's Name o e�6/ .tea License 37}-i Phone,. zg.7G <br /> TYPE OF WORK (Check) : NEW WELL I I DEEPEN / I RECONDITION J / DESTRUCTION /_ <br /> PUMP INSTALLATION /—/ PUMP REPAIR / / PUMP REPLACEMENT <br /> Other / / .... <br /> DISTANCE TO NEAREST: SEPTIC TAINK SEWER LINES PIT PRIVY �f <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER ll <br /> INTENDED USE TYPE 'OF :WELL ' CONSTRUCTION SPECIFICATIONS <br /> Industrial : 'Cable Tool 'DiA ''of Well Excavation <br /> x Domestic/-private:” ..Drilled Dia of...Well Casing <br /> Domestic/public Driven Gauge of Casing - <br /> irrigatibn� ...... ...Gravel Pack, Depth Of Grout Seal <br /> Other ... . . . . .... . ..Rotary.. ........- . ..Type.:of .Grout <br /> 0her. father information <br /> PUMP INSTALLATION: Contractor <br /> _ Type- of Pump w H.P. / <br /> PUMP: REPLACEMENT: State Work Done ..e �V � � �f�lce1 <br /> PUMP 'tEPAIR:. -'. . ......: ..... /. ./ State Work. Done <br /> .DF'-TRUCTION .OF WELL Well"Diameter -- Approximate Depth <br /> Material and Procedure. . <br /> I hereby agree "t6""cb iply with 'al.l laws and regulations of the San Joaquin Local health District <br /> F and. the State,of..California pertaining-to or regulating well 'construction. Within FIFTEEN DAYS <br /> after completion of ;my :.work on a neva we11, I will furnish the San Joaquin Local Health District a . <br /> WELL DRILLERS"REPORT of -.the' wel1' And 'ngtify them before putting the well in use. The above <br /> information-is -tt.ue .to..the. best, of -my. k wled e- and Lief. <br /> SIGNED . LE <br /> . .._. :...... (D PLOT PLAN ON. REQ SE SIDE) <br /> :.. :.. <br /> FOR DEPARTMENT USE ONLY . . . ��- <br /> Ps3ASE I <br /> APP3:TCATIL3i ACCEPTEI]...BY DATE <br /> ADDITIONAL COM1,1ENTS <br /> PHASE II GRO1jT INSPECTION : PHASE III FINAL INSPECTION <br /> INSPECTION,-BY:. DATE:. ...... ... ... ... . .. INSPECTION..BY. . ` DATE : <br /> � CAI.I-•.I=OR.-A�GROUT.-INSFEC�'ION.7P.RIOR-TO_GROUTING:._AND.__F.INAL..INSPECTION.. �.... -r <br /> t 5 .731M <br /> E. H 1426 ! . - <br />