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SAN JOAQUIN LOCAL T:iEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave, , Stockton: , Calif. �m <br /> Telephone: (209) 466-6731. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7.)-,399 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE TSSUED Date Issued 5 l9--1 <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 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 �C ���.�, /�,, �Z�i CENSUS TRACT <br /> Owner's NamePhone �$ <br /> Address 2/ City <br /> Contractor's Named License # ��•2��� Phone" ' <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN /_ / RECONDITION / / DESTRUCTION /-7 <br /> PUMP INSTALLATION % / PUMP REPAIR/ / PUMP REPLACEMENT <br /> Other L/ <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 Cable Tool Dia. of Well Excavation <br /> Domestic/privateDrilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> t <br /> Other Other Information <br /> PUMP 7,NSTALLATION: Contractor �� <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done L h ¢' <br /> PUMP RBPAIR: / / State Work Done <br /> ,pESTRUCtION OF WELL: Well Diameter Approximate Depth <br /> t <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 IState 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 /> SIGNED . c _TITLE <br /> (11RAW PLOT PLAN ON REVERSE SIDE) d <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE A v <br /> ADDITIONAL; COMMENTS <br /> PHASF�,II GR INSPECTION U PHASE III FINAL INSPECTION <br /> INSPECTIW By DATE INSPECTION B: a DATE /�7 2 <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND <br /> FINAL INSPEC I N. ✓/� T e`-- <br /> /72 1M <br /> E H 1426`, '--1, <br />