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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF.:OI'FICE <br /> USE.. 1601 E. Hazelton Ave. , Stockton, Calif. A <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 2Z- <br /> THIS <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED Date Issued ZI- - 6 <br /> (Complete In Triplicate) Z@� - `�30-- C L3 <br /> Application is hereby made. tolthe 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 o the San Joaquin Local Health District. <br /> 4f _1&/t Q eS' CENSUS TRACT <br /> JOB ADDRESS/LOCATION <br /> Owner's dame , .fes Phone <br /> City ' ,t• �" , <br /> Address <br /> Contractorts Namer4• License #�� � Phone <br /> r A, <br /> Iv <br /> TYPE OF WORK (Check): NEW WELL / / DEEPEN / / RECONDITION / / DESTRUCTION <br /> PUMP INSTALLATION ,LV PUMP REPAIR / / PUMP REPLACEMENT /- <br /> Other/ / <br /> E <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 /> IndustrialCable Tool Dia. of Well Excavation <br /> �I Domestic/private � Drilled 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 /> Other Other Information t <br /> PUMP INSTALLATION: Contractor - d� <br /> Type �of Pump E H.P. <br /> s REPLACEMENT: / / State Work Done ' 's "`" <br /> PtJYP . r � <br /> PUMP `tEPAIR: / / State Work Done <br /> I <br /> pFgTRUCTION 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 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 «. i ' ,TLE <br /> p (DRA14 PL . PLAN DST REVERSE SIDE) <br /> F'OR DEPARTMENT USE ONLY <br /> i PHASE I i �� <br /> APPLICATION ACCEPTEB .BY DATE <br /> ' ADDITIONAL COUNTS: <br /> PHASE II GROUT IN ECTION PHA III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROAT INSPECTION PRION TO GROUTING AND FINAL INSPECTION. <br /> .5/73ywr <br />