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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif, <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7.3-7,z <br /> THIS 'PERMIT EXPIRES 1 YEAR FROM DATE ISSUED bate Issued <br /> ' (Complete In Triplicate) <br /> Application is hereby made to.Ithe 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. 1 62 andIthuRule nd Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 31 CENSUS TRACT <br /> ,. <br /> Owner°s Name ° Phone <br /> � r <br /> Address`?/ .� C�7" Com- City. <br /> Contractor's Name 4 License !E 6 Phone:? <br /> TYPE OF WORK" (Check) : NEW WELL DEEPEN /�/ RECONDITION /7 DESTRUCTION 1`7 <br /> PUMP INSTALLATION f f PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other /t / — <br /> t <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS' <br /> Industrial I Cable Tool Dia. of Well Excavation 11 <br />_ _ LDomestic/private 1 //' Drilled Dia. of Well Casing Z - <br />_�_�__ Domestic/public Driven Gauge of Casing O <br /> Irrigation + Gravel Pack Depth of Grout Seal too:,, <br /> Other I Rotary Type of Grout AA j �LA <br /> I Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump NJ <br /> PUMP ENT <br /> P <br /> RELACEM : <br /> _._... . / / State Work Done <br /> PUMP REPAIR: State Work� <br /> Done' <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 DAYS f <br /> after completion of my work on! a new well, I will furnish the San Joaquin Local Health Dist Ct a, ; <br /> WELL DRILLERS REPORT`of the well and notify them before putting the w9,11 in use. The aVov <br /> information is true to the best of my knowledge and belief. 3-9)"76 <br /> SIGNED !! n(� <br /> GL ��� � (� TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) _ ! <br /> FOR P T USE ONLY f <br /> PHASE I ° <br /> APPLICATION ACG DATE <br /> ADDITIONAL CO ,uQ <br /> OUf INSPECTION PRASE IIT FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY r DATE <br /> CALL FOR A GROUT INSPECTION;jPRIOR TO GROUTING AND FINAL INSPECTION. 4 f <br /> E H 1426 7/72 1 <br />