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11 4— <br /> SAN JOAQUIN LOCAL HEALTH ?DISTRICT <br /> FOR Q ICE USE: 1601 E. Hazelton Ave, ,' Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 2 <br /> 7V-- 23i p <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ; Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby ,inade -ep the San Joaquin Local Health- District for 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 the Rules and Regulations of the San Joaquin Local Health District, j <br /> j <br /> � s <br /> JOB ADDRESS/LOCATIONA I&, " CENSUS TRACT <br /> a ' 4 % <br /> .04 <br /> Owner's -NamePhone <br /> _ "' <br /> Address City " <br /> Contractor's Name LicenseUG?� Phone ' <br /> TYPE OF WORK (Check) : NEW WELL/ ` DEEPEN '/_7 RECONDITION /_� DESTRUCTION /`7. <br /> PUMP INSTALLATION / PUS€' REPAIR / / PUMP REPLACEMENT /7 1 <br /> Other /_7 <br /> f DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGEDISPOSAL FIELD CF,SSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation <br /> Domestic/private Drill4'd Dia. of Well Casing <br /> Domestic/public Driven. Gauge of Casing _ C9 <br /> Irrigation Gravel. Pmk Depth of Grout Seal -� <br /> Other =- Rotary Type of Grout ., ,. <br /> I Other Other Information ' �. <br /> ?. <br /> PUMP INSTALLATION: Contractor <br /> Type of Pumpr wr .. H.P. , <br /> PUMP REPLACEMENT; i €i <br /> State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> r <br /> .)DESTRUCTION 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 /> and the State of California pertaining to or regulating well construction. Within FIFTEEN BAYS <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 well and notify them before putting the well in use. The above <br /> information is true o the es of knowledg, and belief. <br /> SIGNED + TITLE ' r <br /> ` (D ' W PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I / <br /> APPLICATION ACCEPTED BY DATE - 9 7 <br /> ADDITIONAL COMMENTS: <br /> PHAS iI G UT INSP C 0 PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE l� 0 �- INSPECTION BY DATE ff <br /> CALL FOR A G T INSPECTION PRIOR TO GROUTING AND FINAL INSPECTI L <br /> E H 1426 f ^,"` 4/72 <br /> e <br />