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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 16031 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.� <br /> THIS PERMIT EXPIRES 1- YEAR FROM DATE ISSUED Date Issued3 <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 complianceIwith San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION &j&CAj1tD ,4 1V Zgajr7 1ST FT�� ' D. CENSUS TRACT <br /> Owner's Name / 1 w G �� Phone 1� <br /> ,�� . <br /> Address �,� City S aC,Ir 70?V <br /> Contractor's Name -� ` U //� ,Q License # W&12 Phone <br /> TYPE OF WORK (Check): NEW WELL /;;,P"ODEEPEN /_% , RECONDITION FT DESTRUCTION <br /> PUMP INSTALLATION, / / PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other <br /> ' rel <br /> DISTANCE TO NEAREST: SEPTIC TANK over- a SEWER LINES PIT PRIVY III <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT' OTHER <br /> ` II <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial able Tool Dia. of Well Excavation ' fl <br /> Domestic/private Drilled Dia. of Well Casing . , <br /> Domestic/public Driven Gauge of Casing. — _ ,,z d X ^ <br /> �rrigation Gravel Pack Depth of Grant Sea1 lil + <br /> Other Rotary w - TypeT of Grout <br /> Other Other Information !�Ln <br /> PUMP INSTALLATION: Contractor S G "1N�,�/z ,f �Q_ <br /> Type of Pump H.P. - . <br /> PUMP REPLACEMENT: /_7 State Work Done <br /> PUMP REPAIR: State Work Done l <br /> .RESTRUCTION OF WELL: Well Diameter <br /> Approximate Depth <br /> Describe Material and Procedure III <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 .m ._kzwwledge and belief. �s-x <br /> ,. { III <br /> SIGNED TITLE�e ; _ <br /> (DRAW PLOT PLAN ON REVERSE SID rE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY �. DATE _< l 3 <br /> ADDITIONAL COMMENTS: �- <br /> PHASE II MOUT INSPECTION PRASE INSPECTION <br /> INSPECTION BY DATE INSPECTION BY/--ZDATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INS E' �II <br /> E H 1426 7/72 IM <br />