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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 /> LICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. '7?--Z�3 tk) <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued <br /> I (Complete In Triplicate) <br /> Application is he y 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 Joaquir <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 12- CENSUS TRACT <br /> Owner's Nam <br /> Phone <br /> Address C + <br /> City <br /> Contractor's Name License # Phone <br /> TYPE OF WORK (Check): NEW WELL / / DEEPEN /L� RECONDITION j DESTRUCTION' /-7 <br /> PUMP INSTALLATION /7'/ PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> Other, 31 <br /> DISTANCE TO NEAREST: ( SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE , TYPE OF WELL CONSTRICTION SPECIFICATIONS -a <br /> _ Industrial ' Cable Tool Dia., of Well Excvation• <br /> Domestic/private Xa <br /> - Drilled I <br /> Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> F Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: .. Contractor <br /> r <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / Sta a Work Done ;. <br /> I PUMP REPAIR. /%: State Work <br /> ESTRUCTION OF WELL: W 1 Dia er <br /> De cr Material aApproximat Depth <br /> nd ocedure <br /> _ r <br /> I,jfereby agree 'to comply with .311 laws and regulations o ' t efSan Joaqu n L cal Health Di trict <br /> and) -the State ,of California pertaining to or regulating well construction. Within FIFTEEN DAYS. <br /> a to completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> WE�L DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> .1itformat'i i, is true to the best of my knowledge and belief. <br /> r` <br /> TITLE <br /> 1 (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> P `SE�~ f <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: DATE r I <br /> PHASE II GROUT INSP CTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY PATE INSPECTION BY . DATE <br /> CALL FOR A GROUT INSPECTION-PRIOR TO GROUTING AND° FINAL INSPECTION. E <br /> E H 1426 <br /> f 7/72 1M <br />