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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. Hazelton Ave. , Stockton, Calif. <br /> eFORFFICE USE°� a, Telephone: (209) 466-6781 f <br /> f APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ? . <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> 3 <br /> (Complete in Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> an Joaquin <br /> and/oar install the work herein described. ThRisulationstofnthe is SaneJoaquinde in pLocal ewith S <br /> HealthDistrict. <br /> County Ordinance No. 1862 and the Rules 8 <br /> Jos ADDRESS/LOCATION �.� �..3� - . -C��,�. ' - "- �9 �y.. - �� cENsus TRACT <br /> fi. <br /> `I� <br /> 3 <br /> Phone ���� 1 / <br /> Owner's Name <br /> � = <br /> City 6'ee _0'1 JD <br /> Address <br /> License �f '� .D Phone . -J3 1. <br /> E Contractor's Nam z - c.i� '�` } i� ' .�_nl <br /> 1 TYPE OF WORK (Check) : NEW.-WELL /� DEEPEN RECONDITION RECONDITION /� DESTRU.0 . '.. /� <br /> ( :'PUMP INSTALLATION PUMP REPAIR � PUMP'REPLACEMENT ITT <br /> ,Other f / �+ <br /> # _ _ 4, °D <br /> DISTANCE-TO NEAREST: SEPTIC TANK *: SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD -CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE !I TYPE OF WELL -CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private] Drilled Dia. of Well.-Casing <br /> Driven Gauge of Casing. �.. <br /> Domestic/public <br /> s ' li.. _ _..._GraveI_P.ackT�--' :Depth""``of-Grout <br /> lrr-igatf on ' - s - <br /> ! �M "Other ': Rotary Type of Grout 's <br /> Other Information <br /> Other .__,. , <br /> PUMP INSTALLATIONS Contractor �' ": ,r� <br /> Type of Pump 'i H.P. tel Q <br /> Work Done <br /> PUMP, REPLACEMENT: ;, / / State411 <br /> PUMP. REPAIR: State Work Done <br /> � T1RUCTION OF WELL: N Well Diameter' Approximate Depth <br /> -DES <br /> Describe Material and Procedure <br /> !� <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 /> F after completion of my work on anew well, I will furnish the San Joaquin7'Local Health District E <br /> WELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> 4 information is true to the best of my knowledge and belief. ' <br /> h <br /> j SIGNED :.• � ' ,� .c� :�,•.�� . TITLE <br /> (VRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE', � 73 <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: PHASE III/FINAL INSPECTION <br /> f PHASE II GROUT INSPECTION INSPECTION BY <br /> DATE <br /> INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. 7/72 1M <br /> E H 1426 <br />