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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> or.;OFFICE USE: 1601. E. Hazelton Ave. , Stockton, Calif. � �r_ wlid <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR' PUMP PERMIT Permit No. 7-5- <br /> THIS <br /> =THIS PERMIT EXPIRES 1 YEAR FROM DATEISSUED Date Issued <br /> (Complete In Triplicate) <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 Sart Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local. Health District. � <br /> ' JOB ADDRESS/LOCATION -a .- CENSUS TRACT <br /> cr - <br /> Owner's Name C' .QC. Phone ;" S.• '39 ,� f <br /> AddressCity <br /> Contractor s Name .-tom,_ - { = �- ;License Jt'�f3Thone (3 <br /> TYPE OF WORK (Check) : NEW WELL -/,37 DEEPEN '/—/ RECONDITION /_/ DESTRUCTION 17_ <br /> PUMP INSTALLATION f PLIMP REPAIR '/ / PUMP REPLACEMENT" /?: <br /> Other 0 I O <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 Cable Tool' Dia. of Well Excavation r <br /> Domestic/private Drilled -Dia. of-Well ;Casing + - <br /> Domestic/public Driven Gauge- of Casing ' <br /> Irrigation Gravel Pack Depth of Grout-.Seal _ <br /> Other ` Rotary Type of Grout T'? <br /> Other Other Information, ' <br /> PUMP INSTALLATION: Contractor ,. <br /> Type of Pum } - F <br /> YP P <br /> 4 <br /> ' PUMP REPLACEMENT: / / State Work Done <br /> T-. <br /> PUMP `2EPAIR: / / State Work Done <br /> ,DFQTRUCTION 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 <br /> E <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 belied.. <br /> SIGNED r 44 <br /> - TITLE <br /> (DRAW PLOT LAN ON REVERSE SIDE_) !/ <br /> -16--75-- <br /> 6-5 (����Gr� DEPARTMENT USE ONLY <br /> PEASE I ujfu <br /> APPLICATION ACCEPT DATE <br /> : <br /> IUT INSPECTION �— PHASE III/FINAL INSPECTION. <br /> INSPECT DATE ,,� INSPECTION BY DATE 12&2/7 _ <br /> `-CALL­F'ORVA•-GROUT INSPECTION-PRIOR,TO 'GRCIU'ING AND FINAL, INSPECTION. . ,I� . ! <br /> E H 1426 11 _ �/Tl i m ! <br />