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i <br /> i SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 - ;l <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 'ZZ "" 7 4�� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED , Date Issued -/ 7Ti <br /> (Complete Tn Triplicate) �� z <br /> Application is hereby made'to the San Joaquin Local Health Distirict far a permit to construct 1 <br /> and/or install the work herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 18A" '1e Rules and Regulations of the San Joaquin Local Health District. f; <br /> JOB ADDRESS/LOCATION 1V�^ '} Oa <br /> CENSUS TRACT OS-old--l3, <br /> Phone <br /> Owner's Name <br /> APjlt �� City <br /> Address 6 <br /> F. <br /> Contractor's Name .Q�.. <br /> License 4�f � Phone <br /> TYPE OF WORK (Check) : NEW-WELL / DEEPEN /_7 RECONDITION /� DESTRUCTION /� ` <br /> PUMP INSTALLATION / / PUMP REPAIRPUMP REPLACEMENT /-T <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD - CESSPOOL/SEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> f I?omestic/public Driven Gauge of Casing <br /> 4 Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout �p• <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor ) <br /> H.P. <br /> Type of Pump <br /> h � <br /> PUMP REPLACEMENT: State Work Done <br /> PUMP REPAIR• / / State Work Done y <br /> ' 1 Approximate Depth <br /> .PEST RUCTION_ OF WELL: Well Diameter <br /> Describe Material and Procedure <br /> 111111111 '"'I'll,I hereby agree to comply with all laws and regull Health District <br /> ations of It" Joaquin Loca <br /> and the State of California pertaining to or regulating well. construction. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish the'lSan 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 /> ' <br /> --2 SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> ;,F FOR DEPARTMENT USE ONLY <br /> f: PHASE I I DATE - <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: ( _ <br /> PHAS II GR N P 0 i PHASE III NAL INSPECTION <br /> INSPECTION BY <br /> DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND' FINAL INSPECTION. 4/72 <br /> # E K 1426 I� _. <br />