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.SAN-JOAQUIN LOCAL HEALTH &STRICT �7d <br /> i<OF.�VFFICE USE: . - "i 1601 E. Hazelton Ave; , Stockton, Calif._= <br /> Telephone: (209) 466-6781 i <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �}�� <br /> - 7z-/--3�9�' <br /> THIS PERMIT EXPIRES I YEAR FROM DATE" ISSUED Date Issued _? <br /> (Complete In Triplicate) Z3-10 0-1() <br /> Application is hereby rade 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 and Regulations of the San Joaquin Local ll.eal.th Districts, <br /> e-N TCENSUS CT " <br /> JOB ADDRESS/LOCATION. O � Od Ie <br /> x S Phone 46 z-Y <br /> 'Owner's Name 4 6; I <br /> Address �2 3 1E A/0 G/ L �o 7 City '�� j <br /> License Phone 46 <br /> Contractor's Name x <br /> TYPE OF WORK (Check) : NEW WELL Ill DEEPEN "./_/ RECONDITION / / DESTRUCTION f? <br /> PUMP INSTALLATION PUMA' REPAIR"/ I PUMP REPLACEMENT I� � <br /> other <br /> j <br /> DISTANCE TO NEAREST: SEPTIC TLNK SEWER LINES _ PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE <br /> TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable ,Tool Dia. of Well Excavation <br /> Domestic/private Drilled t Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation .Gravel Pack Depth of Grout Seal <br /> Other ► "Rotary Type of Grout <br /> Other Other Information <br /> F <br /> PU3-T INSTALLATION: Contractor H.P. <br /> Type of Pump <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP.-tEPAIR: T -/ / State Work Done <br /> Approximate Depth <br /> DF�TRUCTION OF WELL: Well Diameter <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 /> information is true to the best of'• my knowledge and belief. <br /> l J 44�`TITLE <br /> SIGNED <br /> D W L T P41VIN REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> t_ Pi A.SE IDATE 2 <br /> APPLICATION ACCEPTED BY <br /> r <br /> ADDITIONAL COMME4NTS: <br /> Pf1AINSPECTION PHASE III/FINAL INSPECTIODTINSPECTION BYDATE ' INSPECTION BY ,. DATE <br /> aCALL I'OR A GION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> 5/73.im C1 <br />