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0 <br /> ' SAN JOAQUIN 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. 1d <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued.y.,�,,I <br /> I (Complete In Triplicate) 22(0-- 130 ? <br /> Application is hereby- made to the San Joaquin Local Health District for a permit to construct <br /> and/or install the work here=in described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION l:!!;,%!- .. i � Com. <br /> �-: CENSUS TRACT <br /> Owner's Name <br /> Phone ,? r-6 L„2 <br /> Address • <br /> ".�.�...." City .e�.— <br /> Contractor's Name <br /> License #74 Phone <br /> F <br /> TYPE OF}WORK (Check): NEW WELL DEEPEN /? RECONDITION /? DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY SN <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER O <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS, O . <br /> Industrial Cable Tool Dia. of Well Excavation ,CL <br /> Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigations Gravel Pack Depth of Grout Seal <br /> Other I ' Rotar <br /> y Type ,of Grout , <br /> Other `^ Other .Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> H.P.- <br />.PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR- / / State Work Done <br />,E STRUCTION OF WELL: Well Diameter . � - <br /> Descri� e Material and Procedure Approximate Depth <br /> I hereby agree to comply -with all laws and regulations of the San Joaquin Local Health District 4 <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 5 <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 �- �� ' <br /> , -�� TITLE k <br /> DRAW PLOT PLAN ON REVERSE SIDEY- -- <br /> PHASEFOR�, DEPARTMENT USE ONLY <br /> . I'� � -- - - - -- �- - <br /> APPLICATION ACCEPTED BY DAT <br /> ADDITIONAL COAlf <br /> OUT INSPECTIQN P II NAL INSPECTION <br /> INSPECTION DATE &, .:= INSPECTI N B <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M i <br />�_ Y <br />