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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , <br /> Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> PLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> ' Date Issued; /o- _7?_- <br /> (Complete In Triplicate) <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 No. .1 'e,j862 d the Rules and Regulations of the San Joaquin Local Health District. <br /> `f p�� s.' �sem. ,�:l <br /> .TOB ADDRESS/LOCATION �� ,Ie S ate' a � fpm / tel- Bozo.-q <br /> CENSUS TRACT <br /> ' Owner's Name <br /> r `� <br /> Address Phone <br /> ty 2."j /�� �s S o <br /> o a^ �Q4&j�_ ! do Gt/ lidc City <br /> Contractor's Name ' <br /> f License # i, Phone <br /> j TYPE OF WORK (Check): NEW WELL / / DEEPEN RECONDITION' /? DESTRUCTION /7 <br /> PUMP INSTALLATION / PUMP Other REPAIR /` / ` 'PUMP REPLACEMENT /� { <br /> /% <br /> f DISTANCE TO NEAREST: SEPTIC TANK S <br /> k SEWER LINES PIT PRIVY �P <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT �� . <br /> OTHER N7. E <br /> t - INTENDED LTSE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation S� <br /> Domestic/private Drilled Dia, of Well Casing ~ <br />` Domestic/public Driven Gauge of Casing i <br /> Irrigation Gravel Pack Depth o€ Grout Seal <br /> Other - <br /> Rotary Type of Grout I <br /> .. Other 0 <br /> thei Information � <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP PAPA@" / �,/ State Work Done- J - �, ; <br /> ESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure Approximate Depth <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 /> WELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> after completion of my work on a new well, I .w-ill furnish the San Joaquin Local Health District a <br /> 4 <br /> information is true to the best of m knowled-g-e-end belief. <br /> SIGNED' <br /> ar. of TITLE'. . ... <br /> (D W PLOT PLAN ON VERSE SIDE <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY 00, <br /> ADDITIONAL COMMENTS: DATE /a <br /> PHASE II GROUT INSPECTION1 <br /> INSPECTION BY ti DATE _ PHASE IIi FINAL INSPECTION <br /> INSPECTION BY DATE Q <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTIO <br /> E H 1426 <br /> 7/72 1M <br />