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SAN JOAQUIN LOCAL HEALTH DISTRICT � <br /> �OF.:OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. , <br /> Telephone: (209) 466-6781 ' <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. D CJ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUER Date Issued74- <br /> (Complete In Triplicate.) <br /> Application is hereby made to, the San Joaquin Local Health District for a permit to construct <br /> and/or install the work hereix► 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 R� CENSUS TRACT <br /> Owner's Name . s -- Phone <br /> � City <br /> Address S� <br /> Contractor's Name License # Phone ' <br /> 2TYPE OF WORK (Check) : NEW WELL I DEEPEN '/ ..RECONDITION f f DESTRUCTION /`�T <br /> PUMP INSTLATION L'M REPAIR, / 1 PUMP REPLACEMENT /� <br /> AL <br /> Other f f { 14 <br /> U'l <br /> DISTANCE TO NEAREST: SEPTIC TA��iK (,��5 . WER LIES (� d IT PRIVY O 4 "�--- { <br /> SEWAGE DISPOSAL FIELD ,-CESSPOOL/SEEPAGE PIT;��I-f--OTHER �-�— ----(�� <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATI NS <br /> w Industrial -- Cable Tool" Dia., of Well Excavation eF If ` <br /> omesti.c/private i Drilled Dia.:,of_We11,Casing r <br /> Domestic/public I Driven Gauge of�asi�9 : <br /> Irrigation Gravel Pack Depth ofGrout S �' dZ.•�'�u'� <br /> Other -Rotary Type of Grout — <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor �— <br /> Type 'of Pump _ �. H.P. <br /> k PUMP REPLACEMENT: / / State Work Done "` <br /> PUMP `tEPAIR: / / State Work Done . <br /> pFgTRUCTION OF WELL: Well Diameter 3roximate 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 Califoinia��pertaini'►g-'.to"--or regulating well "evnstruction. Within FIFTEEN DAYS <br /> after completion of my work`od anew well,'I will furnish the San` Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well.­and no—ify�-them­befdre-putting the well in use. The above <br /> info tion is true to the be ledge and belief. <br /> SIGNED - TITLE <br /> D PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> P � 7 2r�.a G[e tc R . <br /> APPLICATION ACCEPTED .BY � DATE t <br /> ADDITIONAL,-.COMMENTS cl', <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE f INSPECTION BY. s DATE <br /> R <br /> CALL FOR AROUT INSP_EC,TION PRIOR TO GROUTING AND FINAL INSPECTION:• 5/73 <br />