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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> IOF.7O1?FICE USE* 1601 E. Hazelton Ave. , Stockton, Calif <br />" �, ,W Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 7 4 <br /> "•.�. (Complete In Triplicate) 2Y5-12Z-1�' <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> :wand/oar install the work herein described. • This application is made in compliance with San Joaquin <br /> County Ordinance No.. 1862 acid the Rules and Regulations of the San Joaquin Local: lieal.th District. <br /> = � ."- <br /> ,�OB ADDRESS/LOCATION �" �► NSUS TRACT . V` <br /> VOwner's Name Phoned 1/0, 3 <br /> t - <br /> Address City <br /> Contractor's Name <br /> DL __ _ License �I� PhoneT <br /> - - <br /> TYPE OF WORK' (Check): NEW WELL / DEEPEN '/—/ RECONDITION_/ / DESTRUCTION /_7 <br /> PUIQ INSTALLATION / / PUREPAIR / / PUMP REPLACEMENT -7 <br /> MP <br /> Other /_7 — --- <br /> DISTANCE TO NEAREST: SEPTIC TANK _ 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/private. Drilled Dia. of Well Casing " <br /> Domestic/public f Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal Q <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP yINSTALLATION: Contractor }' <br /> - - - Type of Pump H.P. <br /> PUMP REPLACEMENT: / J State Work Done <br /> i�KP-'tEPAIR: / / State Work-'D'ddd' <br /> ,DF�qTRUCTION 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 wel.l ''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 �/ P4 6Y1l i : TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> �* <br /> FOR DE NT USE ONLY <br /> P <br />`,r lATION ACCEPTE DATE - ZS <br /> AD �IOI�AL CO ' <br /> qo- OUT INSPECTION PHASE I J INAL INSPECTION <br /> R.':F4 <br /> INSPECT B BATE -,9(x.1 _ INSPECTION BY DATE 6-�-7 <br /> • 'FALL FOR'A GROUT• INSPECTION PRIOR TO ROUTING AND FINAL INSPECTION. . <br /> •"ice -t 'e . f r_ r. /*7 1,1 M r <br />