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t ' SAN JOAQUIN LACAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave.', Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WML CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued L-:)._�-�3 <br /> (Complete in Triplicate) 0S2�-o,_0S <br /> Application is';,hereby made to 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. <br /> JOB ADDIZM/LOCATION tv c.. v MXly &W1LrnjYCCENSUS TRACT <br /> Owner's Name Phone, <br /> Address City <br /> Contractor's Name License _z1A4K 7Phone <br /> TYPE OF WORK (Check) : NEW WELLDEEPEN /_7 RECONDITION /_/ DESTRUCTION <br /> PUMP INST LLATION PUi�'°REPAIR / / PUMP REPLACEMENT /7 W <br /> Ither <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _ ® PIT PRIVY C <br /> SEWAGE DISPOSAL FIELDCESSPOOL/SEEPAGE PIT jjj&.f OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS { <br /> Industrial Cable Tool Dia. of Well Excavation z49 /0 <br /> Domestic/private Drilled � Dia. of well Casing <br /> Domestic/public Driven Gauge of Casing. fZ <br /> Irrigation Gravel Pack Depth of Grout Seal �— <br /> Other _ Rotary Type of Grout ,4 <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of,-Pump <br /> PUMP REPLACEMENT: / / State ..Work Done a <br /> PUMP REPAIR: / / State Work Done" , <br /> ESTRUCTION OF WELL: Well Diameterf Ap roximate Dep h <br /> is DescribeMa <br /> tenial and P educe _ <br /> lU <br /> I hereby agree to comply with all laws a d .regulations of the San Joaquin Local Health District <br /> and the State of California pertaining o '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 is true to the best of my knowledge and belief. <br /> SIGNED TITLE <br /> (DRAW,.PLOT PLAN ON REVERSE SIDE <br /> ti FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY ZX DATE `-7 <br /> ADDITIONAL COMMENTS: T <br /> PHASE II G OUT INSPEC 0 PHASE I /FINAL INSPECTION_ <br />[ INSPECTION BY .: DATE. INSPECTION BY DATE <br /> CALL FOR A GROW INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION?/e <br /> E H 1426/ 7/72 1M <br />