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/J1 N JOAQUIN LOCAL HEALTH DISTRIC- <br /> r OR OFF CE USE: 16G_ E. Hazelton Ave. , Stockton, Ca <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. gu-,a 0 9 1,/ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued qy_�{ <br /> (Complete In Triplicate) <br /> )plication 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 Joaquir <br /> 'ounty Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JB ADDRESS/ 9e*TteN vI zzilzu JJCENSUS TRACT <br /> ,,per's Name 7 �, -r��iot?a4e G� � Phone <br /> \ddress _�T �di�ll -�� ��77 City <br /> mtractor's Name � � s � y���� /5 License 6Phone 17 <br /> PE OF WORK (Check) : NEW WELLDEEPEN / J RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INS ALLATION Jai/ PUMP REPAIR / / PUMP REPLACEMENT <br /> Other 7" <br /> STANCE TO NEAREST: SEPTIC TANKSEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIOTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation O <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing / Z <br /> Irrigation Gravel Pack Depth of Grout Seal �- <br /> Other Rotary Type of Grout Gila r <br /> Other Other Information / -- - <br /> "`MP INSTALLATION: Contractor kaftmen <br /> y Type of Pump H.P. — _ <br /> 'UMP REPLACEMENT: / / State Work Done <br /> oeMP REPAIR: / / State Work Done <br /> STRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> d the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> iter completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> 'ELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> formation is true to the best of my knowledge and belief. , <br /> IGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> .. 7 FOR DEPARTMENT USE ONLY <br /> RASE I �y� <br /> "PLICATION ACCEPTED BY_ / Q d jrfjf DATE i <br /> DITIONAL COMMENTS: 7— <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> NSPECTION BY DATE S_��-1y INSPECTION BY DATE 5- CS-q y <br /> CALL I-OR A OUT INSPECTION PRIOR TO GROUTING AND FINAL INS TION. <br /> E H 1426 7/72 1M <br />