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SAN 30AQUIN LOCAL' HLxALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. 7 '/�, <br /> Telephone': (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ?�3 <br /> tIssue <br /> Dated <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED � - <br /> i (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin LoapplicationD stmade inal Health isrict ra permit co pliancetwithnSanuJoaquin <br /> and/or install the work herein describe <br /> d. This County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local health District. <br /> G�1gENSUS TRACT <br /> JOB ADDRESS/LOCATIONG[/M' <br /> � 1 <br /> 0`i Phone <br /> Owner's Name <br /> kCity <br /> Address �/�� :� � q <br /> t License #� 1 Phone <br /> Contractor's Name Y_ n <br /> _ <br /> TYPE OF WORK (Check) : NEW WELL J r - DEEPEN /-7 RECONDTION /P E EPLACEMENT-/7 <br /> PUMP INSTALLATION PUMP REPAIRI- <br /> Others <br /> i � PIT PRLV-Y� <br /> DISTANCE TO NEAREST. SEPTIC TANK SEWER LINE <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> Ul <br /> YINTEND ED USE TYPE OF WELL CONSTRUCTION ---- - ICATIO S <br /> Industrial Cable Tool Dia. of Well Excavation <br /> — Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public _ <br /> Driven Gauge of Casing r <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> - Other Other Information <br /> PUMP INSTALLATION: Contractor —HP. <br /> � Type l of Pump <br /> PUMP REPLACEMENT: <br /> State Work Done <br /> { PUMP REPAIR: _--. ...� I / ` State Work.Done. . <br /> DESTRUCTION OF WEL <br /> SWl Approximate Depth <br /> L: Well Diameter <br /> k Describe Material and Procedure <br /> I hereby agree to comply.,with all laws and regulof the <br /> ell cSan Joaquin <br /> n.LoW 1 I'lealthFIFDistrict <br /> i and the State of Califor'��'a pertaining to or regulating <br /> EEN 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 /> r TITLE <br /> SIGNED <br /> ;.� (DRAW PL PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> 1 <br /> PHASE I DATE <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: PHASE ILJIIIIFINAL INSPECTIO, <br /> PHASE II OUT INSPECTIO INSPECTION BY DATE <br /> INSPECTION BY DATE. <br /> CALL FOR A GROUT -IN ECTION PRIOR .TO GROUTING AND FINAL INSPECTION. :� _ 7/72 1M <br /> E H 1426 �i <br />