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i <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF OFFICE USS: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7th-3�4> <br /> f THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> P (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 San Joaquin: <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION ENSUS TRACT <br /> Owner's Name V Phone p <br />' Address s'Q F5 _ <br /> City _ <br /> f Contractor's Name License �� Phone <br /> TYPE OF WORK (Check): NEW WELL R/ DEEPEN -/—/ RECONDITION / / DESTRUCTION /? <br /> PUMP 'INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /-7 �f <br /> f other �! — a <br /> a ' <br /> DISTANCE TO NEAREST: SEPTICTANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial )tO Cable Tool Dia. of Well Excavation o � <br /> Domestic/private #- Drilled Dia. of Well, Casing <br /> Domestic/public i Driven Gauge of Casing . <br /> Irrigation t Gravel .Pack Depth of'Grout Seal <br /> Other 11 Rotary Type of Grout <br /> Other Other Information I <br /> PUMP INSTALLATION: Contractor qt <br /> Type of Pump H.P. <br /> PUMA' REPLACEMENT.. <br /> F/ J State Work Done <br /> PUMP--PAIR-: �.� /-7 State."Work,Done <br /> DFRTRUCTION 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 /> 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 /> t , <br /> SIGNED L TITLE <br /> I RAW LOT PLAN ON REVERSE SIDE) <br /> PHASE I R DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BYy"S <br /> DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II G SP C c1 PHA IT/ INAL INSPECTION _ <br /> INSPECTION BY AT INSPECTION By DATE 7-,//--2-51" <br /> ---.--CALL FOR A GROUT IN ECTION PRIOR-TO GROUTING AND FINAL INSPECTION. <br /> 14 1L47h 4v/C r- Via— Cru''. r' 17 1,., . <br />