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V� v <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. Hazelton Ave. , Stockton, Calif. <br /> For.,-OFFICE USE: <br /> Telephone: . (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. L9=31LD0 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued .,SSS/_ <br /> (Complete In Tr.iplicate) <br /> Application is hereby made to the San Joaquin Local Health District far 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 AAd the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION I1� ' CENSUS TRACT <br /> Owner's Name L. Phone ' <br /> k Address " . L� F ' l� <br /> City <br /> Contractor's Name <br /> 11,10 <br /> PVIicense 7 Phone �� <br /> I TYPE OF WORK (Check) : NEW -WELL / / DEEPEN/ I RECONDITION /—/ DESTRUCTION /_7 <br /> PUMP INSTALLATION % PUMP REPAIR / / PUMP REPLACEMENT <br /> Other - <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS Cr <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well. Casing <br /> Domestic/public <br /> Driven Gauge of Casing, <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> k Other Rotary. Type of Grout <br /> Other Other Information ' <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: State Werk Done <br /> PUMP `2EPAIR: State Mork Done <br /> DFCTRUCTION OF WELL: Well Diameter Approximate Depth <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 .t-o,or regulating well construction. . Within FIFTEEN DAYS <br /> t miter completion of my work on a new well,`I will furnish the San Joaquin Local Health District <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 /> SIGNED TITLE <br /> } (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> i P1iASE I DATE �1 <br /> APPLICATION ACCEPTED .BY. E. i(3 &CAAZZ <br /> ADDITIONAL CO�lMENTS: PHASE III/FINAL INSPECTION <br /> PHASE II GROUT INSPECTION IX, <br /> INSPECTION BY y. DATE INSPECTION BY.,_ _` _ DATE <br /> .CALL TOR-A-GROUT INSPECTION-PRIOR- TO GROUTING AND FINAL INSPECTION. <br /> r ,. 5/73IN <br />