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FOR OFFIUSE: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> I Permit No. 21- a S <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete In Triplicate) Date Issued S-1 <br /> Application is hereby made to the San Joaquin Local Health District for p mitt tc ns <br /> and/or install the work herein described. <br /> tr <br /> This application is made in compliancewithSanuct Jgaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local H <br /> Ira z . <br /> �-- Health District. <br /> JOS ADDRESS/LOCATION? — ,_ _ <br /> ..4 <br /> CENSUS TRACT <br /> Owner's Name , f <br /> Phoner z <br /> Address 16,5 <br /> i <br /> City <br /> Contractor's Name <br /> License # I Phone 114041S <br /> TYPE OF STORK (Check}t- NEW WELL _ _ f <br /> /�/ TDEEPEN /� `REGONDITION / / s DESTRUCTION / —_ --�--- - <br /> PUMP INSTALLATION / / _PUMP REPAIR / —PUMP PUMP REPLACEMENfi /-7 <br /> Other /-7 <br /> f <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT <br /> OTHER i <br /> INTENDED USE TYPE OF WELL <br />_ Industrial CONSTRUCTION SPECIFICATIONS <br /> - _ <br /> Domestic/private Cable Tool Dia, of well Excavation <br /> Domestic Drilled Dia. of Well Casing <br /> /public Driven _ Gauge of Casing <br /> Irrigation Gravel Pack <br /> Other Depth of Grout Seal <br /> Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump , I <br /> _ H.P. <br /> PUMP REPLACEMENT: <br /> State Work Done 4 <br /> PUMP REPAIR: <br /> State Work Done <br />)ESTRUCTION OF WELL: Well. Diameter "`Approximate e <br /> Describe Material and Procedure Depth <br /> 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 />.fter completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br />'ELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> nformation is true to the best of my knowledge and belief. a <br /> IGNED , <br /> L�� <br /> TITLE , <br /> (DRAW P T PLAN ON REVERSE SIDE <br /> RASE I FOR DEP TMENT USE ONLY <br /> PPLICATION ACCEPTED BY <br />)DITIONAL COMMENTS: DATE <br /> PHASE II GROUT INSPECTION PHASE II FINAL INSPECTION <br /> JSPECTION BY DATE INSPECTION BY <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. DATE <br /> E H 1426 <br /> 7/72 1M <br />