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/ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OF E USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> I 'Telephone : (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> 'I <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> i (Complete In Triplicate) <br /> Application is herebyi-made toy;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. 1862 and. the Rules and Regulations of the San Joaquin Local Health District. � <br /> JOB ADDRESS/LOCATION d;,211Z, ��� �� �� ,1� - CENSUS TRACT <br /> Owner's Name � r � Phone PZ C3 2 v/ <br /> Address �,,..�. - _,..,,.._. City <br /> Contractor's Name License # Phone <br /> TYPE OF WOA. (Check): _',NEW WELL / / DEEPEN / / RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INS�TION / / PUMP REPAIR / / PUMP REPLACEMENT /� <br /> Other <br /> j <br /> DISTANCE TO NEAREST: SEPTIC TANK LINES - PIT PRIVY <br /> SEWAGE DISPOSAL FIELD OL/SEEPAGE PIT---------OTHER--- <br /> 1 f <br /> INTENDED USE TYPE OF. WELL CONSTRUCTION SPECIFICATIONS - <br /> Industrial I Cable Tool Dia. of Well Excavation <br /> Domestic/private it' Drilled Dia. of Well Casing <br /> Domestic/public I Driven Gauge of Casing �_Z <br />. Irrigation t Gravel Pack Depth of Grout Seal <br /> Other f1 Rotary Type of Grout ; <br /> i Other Other Inf orma "io F <br /> f � a <br /> Q--9 <br /> PUMP INSTALLATION: Contractor ✓ r <br /> Type of Pump H.P. ' <br /> T <br /> PUMP REPLACEMENT: / / State Work Don � <br /> PUMP REPAIR: / / Sate Work Do <br />.RESTRUCTION OF WELL.: Well Diameter _ Approximate Depth <br /> - — Describe Material ndPro lure <br /> :f f <br /> I hereby agree to comply with-'all lawZand' gulations of the San Joaquin Local Health District <br /> and the State of California pertaininr.e ulating well construction. Within FIFTEEN DAYS <br /> after completion of my work on a new ill furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well andhem before putting the well in use. The above <br /> information is true to the best of my knowledg 2anU-belief:"' <br /> SIGNED f- - TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT-USE-ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY1, DATE P_>3 <br /> PHASE II ROUT PECTION - -- -. .. ' PHASE -IIT FINAL -INSPECTION.. + <br /> ADDITIONAL COMMENTS: _ - <br /> - <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. f <br /> E H 1426 7/72 1MC c - <br />