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r / <br /> / SAN JOAQUIlf--,LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR;:WELL,,CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRt��t1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made 'to the San Joaquin Local Health District for a permit to construct <br /> j and/or install the work herein described. This application is made in compliance with San Joaquin <br /> l County Ordinance 'No. 1862 ap"d the Rules and RegulatioDs of the San Joaquin Local Health 'Distriet. <br /> r , j7 r X--7 <br /> f JOB ADDRESS/LOCATION Zgl p? /�I z o eft CENSUS TRACT <br /> Owner's Name S.9 ;f s s az A Phone 3Z,?„y 7q* <br /> Address City <br /> Contracto_ r''s`Name' a s:,a� _mac /Gi aT_.. ,�f� xLicense�Li fig. A one - <br /> ! - <br /> TYPE OF WORK (Check) : NEW WELL /T DEEPEN /_/ RECONDITION /-7 DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP 'REPLACEMENT /7 <br /> Other /-7 <br /> DISTANCE TO NEAREST: SEPTIC TANK A SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> er <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial _� Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled, Dia. -of Well Casing _ N <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation ';° Gravel Pack Depth of Grout Seal <br /> Others Rotary Type of Grout <br /> it Other Other Information' <br /> PUMP INSTALLATION: Contractor <br /> Type <br /> ' of Pump J � H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> • ..-. -.wr._ _,.�-a_._..._. - ..__�� -.--, _ ...e-r.r+-a'arc. aNw;,.•.•- _�+....r_ w-+.eicJ`aw�eA.r. 1r F�YYer'.�wiles ��..N AI�Mn� <br /> PUMP REPAIR: / / State Work Done <br /> ESTRUCTION 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 to or regulating well construction. Within FIFTEEN DAYS <br /> after completion of my workon a new well -. I will furnish the San, Joaquin Local Health District a <br /> WELL DRILLERS REPORT of thc,well and notil'ykTthem before putting the well in use. The:--above <br /> information is true to .the-best of my- knowledge and belief. d <br /> SIGNED TITLE �2-�'C/ <br /> z <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II •GROUT ;INSPECTION PHASE III FINAL .INSPECTION <br /> INSPECTION'�BY PTE INSPECTION BY DATE <br /> ` y 3dr <br /> CALL FOR A GROUT INSPECTION PRIOR TO ,GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />