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CSAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OF ICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PULP PERMIT Permit No. <br /> THIS PERMIT EXPIRES -1 YEAR FROM DATE ISSUED Date Issued .L- o -7 3 r <br /> (Co'MP <br /> 'lete In Triplicate) ., <br /> Application is hereby made to-the San Joaquin Local Health District 'foi `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 and:1the Rules and Regulations of- the San Joaquin Local Health District. <br /> 33,22 CENSUS TRACT <br /> JOB ADDRESS/LOCATION I �iE7 <br /> Owner's Name �igRMn.S - Phone <br /> City <br /> Address - '� <br /> Contractor's Name �c.t6 cam:•� __ 4 f icense #,,J, Phone ' <br /> TYPE OF WORK (Check) : NEW WELL / DEEPE,N P�M� <br /> ECONDITION; DESTRUCTIONPUMP INSTALLATION /+�/ /�REPAIk'/ / PUMP REPLACEMENT I�T <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC •TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> _ t <br /> INTENDED USE TYPE OF WELL j CONSTRUCTION SPECIFICATIONS -� <br /> Industrial it Cable Tool Dia. of Well Excavation <br /> Domestic/private ;I Drilled_ Dia. -. of Well Casing <br /> Domestic/public t Driven Gauge of Casing <br /> Irrigation ;l Gravel Pack. Depth of Grout- Seal <br /> • Other l Rotary Type of Grout <br /> 0 Other Other' Information <br /> PUMP INSTALLATION: Contractor S �✓ !� H.P. <br /> Type of IIPump I r � 40 4A <br /> PUMP REPLACEMENT: / / State Work Done fti <br /> PUMP REPAIR: �"""° ""��/'" TS'tat'e"Wotk-Done <br /> .RESTRUCTION 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 /> hand the State of California pertaining to or regulating well construction. . Within FIFTEEN DAYS <br /> after completion of my wank 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 /> f information is true to th '` est-of my knowledge and belief. <br /> { <br /> l <br /> TITLE <br /> SIGNED <br /> r t (DRAW PLOT PLAN ON REVERSE SIDE7 . r <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY ec!/do ; DATE <br /> ADDITIONAL COMMENTS: I <br /> PHASE II G OUT INSPECTION PHAS I IFI INSPECTION <br /> i -INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT NSPECTION PRIOR .TO GROUTING AND FINAL INSPECT <br /> �, E H 1426 - 7/72 1M <br />