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V <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE US : 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.., <br /> THIS PERMIT EXPIRES 'I YEAR FROM.DATE -ISSUED. Date Issued `=�-�3 <br /> (Complete In Triplicate), , , 05FL- <br /> Application is hereby made 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 ani :77T7the_Rules .and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 71f .(s em. -{� �•,c ��e �. CENSUS TRACT <br /> Owner's Name - - Phone <br /> Address 7 '� Cit r <br /> Y _ <br /> Contractor's Name License #1_6,13 Phone3( - <br /> r 373 <br /> TYPE-OF WORK—(Check): ' `NEW-WEI;L / / 'DEEPEN /�/y RECONDITION/_7 'DESTRUCTION <br /> AL —­PUMP <br /> PUMP INSTLATION PUMP �REPAIR —_PUMP REPLACEMENT /7 <br /> Other /_7 <br /> �� — <br /> DISTANCE TO NEAREST: SEPTIC TANK-----r—__WER LINES SPIT PRIVY ,J <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER �1 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial t Cable Tool Dia, of Well Excavation <br /> Domestic/private E Drilled Dia. of Well Casing11 _ <br /> Domestic/public I Driven Gauge of Casing' <br /> Irrigation ! Gravel Pack Depth of Grout Seal - <br /> Other t Rotary Type of Grout ? <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> p <br /> Type of Pump H.P. <br /> 1 <br /> PUMP REPLACEMENT: / J State Work Done <br /> PUMP REPAIR, State Work Done <br /> .RESTRUCTION OF WELL: Well Diameter yApproxiryate 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 work on a new well, ,I will furnish the San Joaquin' Local Health District a <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 ,�9'Lt�..•� i <br /> TITLE <br /> (29W PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE .ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: - — <br /> PHASE II GRO PECT ON PRA S III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY <br /> CALL FOR A GROUT. INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. � <br /> E H 1426 <br /> 7/72 1M <br />