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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOr., 0 10E USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> 'S Telephone: (.209) 466-6781 j , <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. _ W <br /> `THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued L// 75L <br /> 1 (Complete In Triplicate) ""7" <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. 1.862 and the Rules and Regulations of the San Joaquin Local Health Dishri+ct. <br /> i .TOB ADDRESS/LOCATION CENSUS TRACT � r~ <br /> Owner's Name, z Phone <br /> Add-dss <br /> .-_. �'D _ .5zlo city . . iazt <br /> Contractor's Name i.� License Q%0&� Phone <br /> - - - ; <br /> TYPE OF WORK (Check) : NEW WELL '/0 DEEPEN '/—/ RECONDITION /—/ DESTRUCTION /_7 <br /> .PUMP INSTALLATION I / PUMP REPAIR ,/—/ PUI-' REPLACEMENT /—T <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER o <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial. Cable Tool Dia. of Well Excavation � <br /> _ /p g <br /> Domestic/private Drilled Dia. o£ Well Cason <br /> Domestic/public -- Driven Gauge of Casing /z ally %N1 <br /> Irrigation Gravel Pack Depth of Grout Sdal 1197' <br /> Other Rotary Type of Grout <br /> 2 <br /> Other Other Information G-- _ <br /> k PUMP INSTALLATION: :Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP 'tEPAIR: / / State Work Done <br /> DRGTRUCTION 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 /> E 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 2 The above ' <br /> information .is true to the best of my knowledge and belief. <br /> 6 <br /> SIGNEDTITLE . <br /> . (D PLOT LAV ON REVERSE SIDE <br /> FOR P .TMENT USE ONLY <br /> R <br /> PHASE I .�. <br /> APPLICATION ACCEPTED Y ` DATE <br /> ADDITIONAL COYZ1E <br /> P II OUT INSPECTION P I AL INSPECTION/ / <br /> INSPECTIBY r' DATE �� INSPECTIO DATE /� _ <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> ._--=E H 1426 5/7311 ; <br />