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1 _ - _ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FORAOFFICE USE: I� 1601 E. Hazelton Ave. ,; 'Stockton, Calif. <br /> `I Telephone: '. (209), 466-5781 j <br /> PLICATION FOR WELLCONSTRUCTION OR PUMP PERMIT Permit No. -�'-- l <br /> � THIS PERMIT'EXPIRES 1 YEAR FROM .DATE ISSUED Date Issued <br /> >; <br /> (Complete <br /> Application is- here road p In Triplicate) , <br /> y e 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 tJ. he'°Rules -diid' Regulations. of the Sari Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION y?91 I :C ENSUS TRA <br /> Owner's Name eC�i% xa , <br /> ' ' .. 'Phone <br /> Addreh s _ <br /> City <br /> Contractor's Name License # 2 <br /> I� 37 Phone + <br /> TYPE SOF WORK (Check) : NEW WELL / / DEEPEN / / RECONDITION /_7 DESTRUCTION _ -� <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REP <br /> Other /�/ LACEMENT/ <br /> � <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PTT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> UNTENDED USE TYPE OF WELL <br /> CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation <br /> (Domestic/private Drilled Dia, of Well Casing <br /> wf <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation -----rt__ Gravel Pack Depth of Grout Seal ! <br /> Other Rotary Type of Grout <br /> - Other Other Information <br /> Illi. I � <br /> ` <br /> If <br /> PUMP INSTALLATION: . r <br /> C lontractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: /.I�/ State Work Done <br />.PUMP .REPAIR:- State Work Done <br /> f <br /> ESTRU�CTION OF WELL: We111 Diameter <br /> Describe Material and Procedure Approximate Depth <br /> �I� <br /> I hereby agree to comply -ith.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 DR41 <br /> ILLERS 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 <br /> r TITLE <br /> l` ( W PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE 1� <br /> APPLICATION ACCEPTED BY DATEa- <br /> ADDITIONAL COMMENTS: �M <br /> I PHASE II GROUT INSPECTION PHASE I I FINAL INSPECTION <br /> INSPECT-ION BY I. DATE INSPECTION BY ` DATE <br /> CALZ.I� FOR A GROUT INSPECTION PRIOR..TO GROUTING AND FINAL INSPECTION. <br /> E H �s 426 i� 7/72 IM <br />