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t ij-0 <br /> k SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone.: (209) 466--6781 <br /> I. APPLICATION FOR WELL' CONSTRUCTION OR PUMP PERMIT Permit No. _�gb <br /> I� <br />} THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued - <br /> (Complete In Triplicate) - " - 1 <br /> Application is hereby made t'o the San Joaquin Local Health District far 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 of the San Joaquin Local Health District: ': <br /> JOB ADDRESS/LOCATION7- <br /> _� CENSUS TRACT <br /> fOw er's Name MAS eL EA <br /> .0 R AC C cc,. Phone -- <br /> Address R 9Lq D City A—ERCA,c-12-CAM P c.A eiAZ-j <br /> CoAtractor's Name <br /> License #•z6 t Phone zea<,? <br /> TYPE OF WORK (Check): NEW WILL j '/ DEEPEN /-T RECONDITION } <br /> /� DESTRUCTION /�� <br /> PUMP INSTALLATION j / PUMP REPAIR / / PUMP REPLACEMENT <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 <br /> CONSTRUCTION SPECIFICATIONS <br /> Industrial l Cable Tool Dia. of Well Excavation <br /> Domestic/private I Drilled Dia, of Well Casing DDD <br /> i� Domestic/public I Driven Gauge of Casing tiv <br /> 01. Irrigation Gravel Pack Depth of Grout Seal <br /> Other - I Rotary Type of Grout <br /> l k Other Other Information <br /> IIS: <br /> PUMP INSTALLATIONS Contractor <br /> Type o}f Pump H.P. <br /> PUMP REPLACEMENT: 1 State Work Done <br /> PUMP REPAIR. J / State Work Done <br /> .DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure` <br /> I hereby agree to comply withiall laws and regulations of the San Joaquin Local Health District <br /> and ithe 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 <br /> WELL-DRILLERS REPORT of the well and notify them before putting the well in use. The above a <br /> information is true to the best of my knowledge and belief. <br /> SIGNED ITLE �- <br /> i <br /> (DRAW-PL T PYA ON REVERSE SIDE <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY F // <br /> DATE 2 3 <br /> ADDITIONAL COMMENTS: � I <br /> PHASE II GROUT I PECTION PHASE III FINAL INSPECTION I <br /> INSPECTION BY DATE INSPECTION BX DATE <br /> I <br /> ALL FOR A GROUT IkISPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> & H 1426 <br /> Ij 7/72 1M <br />