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LK SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> IOF.';OFkIC�: USE: E. Hazelton Ave. , -Stockton, Calif. 2?or ZZ <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT permit No. 7 � <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 6-4-7 <br /> (Complete in Triplicate) <br /> t 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 /> r CENSUS TRACT <br /> JOB ADDRESS/LOCATION <br /> 3 <br /> zn- 99 Phone <br /> Owner's Name <br /> �. City '-. <br /> i Address L� - t <br /> 3 Contractor's Nam <br /> License *1 2 Phone-1 <br /> YO <br /> TYPE OF WORK (Check): NEW WELL '/,V DEEPEN I I RECONDITION_/ / DESTRUCTION j? <br /> PUMA' INSTALLATION / / PUMP REPAIR,/ / PUMP REPLACEMENT I� W <br /> Other /-7 <br /> DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER r- , <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of We11 Excavation <br /> Domestic/privatex Drilled Dia. of We11..Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth• of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type bf Pump H,P. <br /> PUMP REPLACEMENT: / I State Work Done <br /> State Work Done- <br /> 1 —�_ <br /> DF9TRUCTION 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 /> 1 . and the. State of California -pertaining to or regulating well "construction. Within FIFTEEN DAYS <br /> i after completion of my work on a new well, I will furnish the San Joaquin Local Health District <br /> WELL DRILLERS REPORT ofithe 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 /> i ,SIGNED � TITLEL��-� <br /> i (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR T�`iENT USE ONLY <br /> N <br /> t PHASE I DATE ��- <br /> APPLICATION ACCEPTED . <br /> ADDITIONAL COMMENTS: - 6- 1 a.�0 <br /> PHASE II 0 T AI C l PHASE I /FINAL INSPECTION <br /> INSPECTION BY Ate_ INSECTiON BY DATE <br /> CALL <br /> FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL iNSP ION. <br /> 5/731M <br /> 'i426. <br />