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t r� SAN.JOAQUIN LOCAL HEALTH DISTRICT. <br /> FOR OFFICE USE: :1601 E. Har-altt Ave, , Stockton, Calif. <br /> Telephone: ` (204) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> a <br /> THIS PERMIT EXPIRES' l' YE'AR FROM DATE ISSUED Date Issued <br /> " • <br /> Application is hereb � (Complete 'In Triplicate) <br /> y- 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;*. 1862-and the Rules and Regulations of the San Joaquin Local health District. <br /> JOB ADDRESS/LOCATION WILL <br /> Q CENSUS TRACT <br /> Owner's Name <br /> ' Phone- <br /> Address Phone Address <br /> city s. I Crrt�C Q- 1� <br /> Contractor's Name <br /> 1 <br /> License # &ZZ,/hone _ <br /> i TYPE OF WORK (Check) NEW WELL / DEEPEN ' ^` - <br /> _/_� RECONDITION /_7 DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other 1/7 <br /> DISTANCE TO NEAREST: SEPTICJANK SEWER LINES PIT PRIVY <br /> SEWAGE 'DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE � <br /> TYPE OF WELL CONSTRUCTION SPECIFICATIONS r <br /> Industrial I Cable Tool Dia. of Well Excavation i <br /> l/Domestic/private gilled Dia. of Well, Casing <br /> Domestic/public i Driven Gauge of Casing <br /> Irrigation t Gravel Pack Depth of Grout Seal G <br /> Other r L Rotary Type of Grout <br /> 1 Other Other Information *9 469 <br /> PUMP INSTALLATION: Contractor v <br /> Type of Pump 4,.V 5 <br /> I Gr- <br /> H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: <br /> / / State Work bone <br />..`pEST£t_UCTION OF WELL: Well Diameter - <br /> "' — <br /> Describe Material and Procedure pproximate Depth <br /> I�,hereby agree to comply with-'all laws and regulations of the San Joaquin Local Health District <br /> and the State of California pe"rtaining 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 <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) t <br /> FOR PAR <br /> PHASE I N USE ONLY r <br /> i <br /> APPLICATION ACCEPTED <br /> ADDITIONAL COMMENT DATE <br /> P ROUT INSPECTION P I F AL­INNS PECTI <br /> ON <br /> iNSPECTIO BY DATE INSPEC BY ATE <br /> CALL FOR A. GROUT INSPECTION-PRIOR TO GROUTING.AND FINAL INSPECTION. <br /> E H 1426 <br /> - _ �• 7/72 1M C'( <br />