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. <br /> k FOR OFFICE USE: SAN JOAQUIN LOCAL <br /> 1601 E. HEALTH DISTRICT <br /> i # Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> f APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> Permit No. <br /> THIS PERMIT EXPIRES Z YEAR FROM DATE ISSUED <br /> Date Issued <br /> Application is hereby made to `the San (Joaquin Loc 1 Health Districpermt - <br /> struct <br /> and/or install the work herein described, t for a <br /> County Ordinance No. This application is made in compliance twith nSan Joaquin <br /> 1862 and the Rules and' Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS&&CATION ��o�� <br /> CENSUS TRACT .5 of <br /> Owner's Name ` <br /> Address <br /> Phone aail,Contractor's Name City <br /> c c< License&/U6�/ phone c3�9 y6/c� <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN ,. <br /> /� RECONDITION /_� DESTRUCTION /_7PUMP INSTALLATION /PUMP REPAIR / / PUMP REPLACEMENT <br /> Other /% <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD <br /> INTENDED USE <br /> CESSPOOL/SEEPAGE PIT OTHER <br /> � <br /> TYPE OF WELL <br /> Industrial CONSTRUCTION SPECIFICATIONS <br /> Cable Tool <br /> Domestic/private Dia. of Well Excavation °i <br /> _ Drilled Dia. of Well Casing LA <br /> t Driven <br /> Irrigation 1� Gravel Pack Gauge_of Casing r <br /> Other Depth of Grout Seal <br /> Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION; Contractor <br /> Type of Pump <br /> H•P• o /% , <br />'UMP REPLACEMENT; Ll State Work Done <br /> 2E REPAIR: / / State Work Done <br /> ESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure Approximate Depth <br /> hereby agree to comply with all laws and regulations of the ,.San Joaquin Local Health�Di <br /> ad the State of California pertainingstrict <br /> Eter completion of my work on a new well,oI will lfurnish ethe ll cSan tJoaquin•Local hHealth in DEN DAYS <br /> ELL DRILLERS REPORT of the well and notify them before putting the well in use. The abDist <br /> overict a <br /> iformation is true to the best of my knowledge and belief. <br />:GNED .. <br /> TITLE # <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> -------------- <br /> ASE I FOR DEPARTMENT USE ONLY <br />'PLICATION ACCEPTED BY <br /> DITIONAL COMMENTS: - DATE <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> SPECTION BY DATEi <br /> INSPECTION BY DATE - <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 <br /> 7/72 im <br />