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b, <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601. E. Hazelton Ave. , Stockton, Calif. Jw �- 2 �U` /o <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. -74.7? <br /> THIS. PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued IZ 1 7 Z <br /> (Complete In Triplicate) j <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 Na. 1$62 an theRules a R lations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION J F � t <br /> /6 CENSUS TRACT <br /> Owner's Name ! ri, , - hones/ :`c moi" <br /> Address _C- / City <br /> Contractor's Name L ? '/� /> �� "<' License # ;1/''�p Phone <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN /_/ RECONDITION /7 DESTRUCTION /7 <br /> PUMP INSTALLATION / PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other / / ^�. �. , r� <br /> DISTANCE TO NEAREST; SEPTIC TAMC �p SEWER LINESp _ PIT PRIVY <br /> SEWAGE DISPOSAL F1i. D CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing O <br /> Irrigation Gravel-Pack Depth of Grout -Seal - - ---- - - ' <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump . f ,_C441 — H.P. <br /> TT: , <br /> PUMP REPLACEMENT: / S tate Work Done < £ <br /> PUMP REPAIR: / / State Work Dane - - <br /> { <br /> .DESTRUCTION OF WELL: Well Diameter (, Approximate Depth <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 a <br /> WELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> informatiVi, ruetothe befit ofjmy knowledge and belief. <br /> SIGNED �i�� _� CJP /1�-� . TITLEra, <br /> J��[l�i <br /> D W PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY _ ,.. 01 DATE 7 7� <br /> ADDITIONAL COMMENTS: . <br /> PHASE II ROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE• a ]z., <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 4/72 1M <br />