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V ~ ' <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> I Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Zlf_ /SJ <br /> THIS: PERMIT EXPIRES l'YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made to, the San ,. aquin 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'r',the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION I 'raENSUS TRACT — <br /> Owner's NamePhone 239-3525_ <br /> Address Center--St; Manteca, Calidormia 5336 City - -� <br /> Contractor's Name Ce' License #A-f-Le 6phone ��5 <br /> TYPE OF WORK (Check) : NEW WELL /7 DEEPEN /_/ RECONDITION /_7 DESTRUCTION /rT <br /> PUMP INSTALLATION J / PUMP REPAIR / / PUMP REPLACEMENT <br /> DISTANCE"TO"NEAREST:"`SEPTIC TANK' + SEWER LINES PIT PRIVY -- <br /> SEWAGE DISPOSAL FIELD_ ;. - CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED`USE� TY'PE' OF�WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial I Cable Tool i Dia, of Well Excavation <br /> Domestic/private I Drilled ' ; Dia. of Well Casing <br /> Domestic/public I Driven i Gauge of Casing <br /> Irrigation k. Graved Pack . Depth of ,Grout Seal , <br /> -- Other Rotary i. Type of Grout --- _� <br /> Other.!; 4 Other Information � <br /> s <br /> PUMP INSTALLATION: Contractor C<..0 V21 <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done s <br /> ESTRUCTION OF WELL: Well Diameter 7, Approximate.Depth <br /> Describe Material, and Procedure <br />' I hereby agree to comply�withiall 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 Distritt a � <br /> WELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> information is true toCtke best of my knowledge and belief. <br /> SIGNED - <br /> (DPLOT PLAN ON -REVERSE SIDE $ <br /> FOR DEPARTMENT USE ONLY <br /> , . <br /> PHASE I- <br /> APPLICATION ACCEPTED BY '? "' DATE �3 - X <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE k <br /> CALL. FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSP ION. <br /> 7/72 1M <br /> E H 1426 <br />