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SAN JOAQUIN LOCAL HEALTH DISTRICT A, <br /> FOR 0 F C1`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 Issued ' <br /> (Complete- In Triplicate) <br /> made to�the- San.Joaquin Local Health District for a permit to construct <br /> Application is .hereby: <br /> aquin <br /> and/or install the work herein described. This uia�ionstofnthe Sa-a JoaquinpeS <br /> LocalHealthDistrict. <br /> County`Ordinance-No:. 1862:.and�the Rules' and g <br /> CENSUS TRACT J � <br /> JOB ADDRESS/LOCATION <br /> Phone <br /> Owner.'s Name:' <br /> City <br /> VA <br /> Address _ <br /> License # �� Phone i <br /> Contractor's Name <br /> TION <br /> TYPE OF WORK {Check) : NEW WELL DEEPEN -/ RECONDITION I pPEREpLACEMENT�/�7 <br /> PUMP INSTALLATION / PUMP REPAIR } <br /> Other <br /> SEWER LINES PIT PRIVY <br /> DISTANCE TO NEAREST:. SEPTIC TANK OTHER <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT <br /> I TYPE OF WELL CONSTRUCTION SPECIFICATIONS 'z <br /> INTENBED USE Dia. of Well Excavation <br /> Industrial Cable Tool <br /> Drilled Dia. of Well Casing <br /> Domestic/privateDriven Gauge of Casing <br /> Domestic/public <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other RotaryType of Grout <br /> ` <br /> other _ other Information <br /> � PUMP INSTALLATION. Contractor H.P. <br /> Type,of Pump <br /> PUMP REPLACEMENT: / / ' State Work Done <br /> PUMP REPAIR: ` / / State Work Done <br /> Approximate Depth <br /> DESTRUCTION OF WELL:" Well Diameter' <br /> Describe Material and Procedure <br /> I hereby agree to comely <br /> wAYS <br /> ith all laws and regulations of the San Joaquin Local Health District <br /> I and9the State of California pertaining or I reguwilllfurnshating ethell CSant3oaquin.Local HealtWithin hDistEEN ricta <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 /> information is true to the best of my knowledge and belief. <br /> 0,11 55� A4 ;lInt TITLE <br /> SIGNED <br /> {DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE-.I.c' ` DATE ��- <br /> APPLICATiON ACCEPTED BY <br /> ADDITIONAL COMMENTS: f PHASE FINAL INSPECTION <br /> PHASE II GROUT INSPECTION "INSPECTION BY <br /> INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION.,.,PRXOR TO GROUTING AND FINAL INSPECTION. 4/72 1M <br /> E H '1426 • <br />