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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE U'Sg: 1601 E. Hazelton Ave ; -Stockton, Calif. <br /> Telephone{ ' (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.,�E_ .- E/ <br /> F <br /> THIS _PERMITsEXPIRES '1 YEAR FROM DATE 'ISSUED " Date Issued <br /> Triplicate.)licate.) R > <br /> Application is hereby made to the `Sari` Joaquin Local..Health District f6r" a permit,"to }const.ruct <br /> and/or install the work herein described. This°application is made in compliance with San Joaquin! <br /> County Ordinance No. 1862 and the -Rules and Regulations' of the San Jbaquin Local Health District. <br /> ..r. =CEN5US,;TRACT ' <br /> Jos ADDRESS/LO TION j . <br /> :. <br /> Owner's Name _ - `Phone w <br /> Address o _ BOAC tis_�� _ City.. <br /> Contractor's Name X35 License 1141A Phone <br /> TYPE OF WORK (Check): NEW WELL / DEEPEN / / RECONDITION /� DESTRUCTION /� <br /> PUMP INSTETION / / PUMP REPAIR / / PUMP REPLACEMENT /? <br />` Other /_7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LI'PES PIT PRIVY G' <br /> SEWAGE DISPO FIELD, �a CESSPOOL/SEEPAGE PIT OTHER 14t ' <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial -Cable Tool Dia. of Well Excavation <br /> fDomestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing ,f <br />} Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other" Other Information <br /> PUMP INSTALLATION: Contractor- <br /> .Type of'°Pump Hr'P. <br /> PUMP REPLACEMENT: " } / / '.,State Work Done r <br /> PUMP REPAIR: / / State Work Done` ---- <br /> � . <br /> ' ESTRUCTTON_OF WELL: Well .Diame-ter- 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 /> and the State of California pertainingito 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 <br /> $ WELL DRILLERS,REPORT of 'the well and notify them before putting the well in use: The above <br /> ; information true to- thebe of my knowledge and belief. <br /> ti�l " <br /> SIGNED 2�--~ ,- 1 TITLE <br /> (D PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY 4 <br /> PHASE DATE <br /> APPLICATION ACCEPTED BY - <br /> : ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PRASE III INAL INSPECTION <br /> INSPECTION BY DATE �-/ '73 INSPECTION BY DATE !� - 17 _ <br /> CALL FOR A GROUT INSPECTION .PRIOR .TO GROUTING AND FINAL INSPECTION. " <br /> E H 1426 - x7/72 1M <br />