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� r SAN JOAQUIN LOCAL HEALTH DISTRICT s <br /> 1 <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6751 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ,,--f-� <br /> THIS PERMIT EXPIRES 1' PEAR FROM DATE ISSUEDI �D��'aissued L �?k •_7S <br /> EYb _ iF <br /> (Complete In Tri.pli ate) <br /> Application is hereby made to the San Joaquin Local Health "District for a permit to construct j <br /> pplication is made i <br /> and/or install the work herein described. This an compliance with. San Joaquin <br /> County Ordinance, No. ::18 2 and the Rules and Regulations of the San Joaquin Local Kealth_, District. <br /> ELI? E.JOB ADDRESS/LOCATION �i•�- ✓ CSUS TRACT ) <br /> T <br /> Phone <br /> Owner's Name <br /> I� <br /> City a <br /> Address <br /> " Contractor's Name � License # Phone -2�3 <br /> p � t <br /> TYPE OF WORK {.Check) : NEW WELL / I DEEPEN I I RECONDITION /� DESTRUCTION I� �` <br /> PUMP INSTALLATION PUMP PAIR^ / PUMP REPLAC NT . /7 <br /> �� = '�, <br /> DISTANCE TO DEAREST: SEPTIC TANK S WER LINES P T PRIVY <br /> . SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Drilled Dia. of Well Casing <br /> , Domestic/private - <br /> Domestic/public Driven Gauge of Casing ` <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Al <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor z- � -f <br /> Type of Pump H.P. ! ;k Y <br /> PUMP REPLACEMENT: / / State Work Done <br /> � PUMP REPAIR: / I <br /> State Work Done <br /> A roximate Depth d <br /> }?FSTRUCTION_OF WELL:_. Well„DiameterY J <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 FIFTEENi�DAYS <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health Distridt 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 be*t of my knowledge and belief. !Ih <br /> TITLE �r e.��- '�'�` •n <br /> SIGNED <br /> (DRAW PLOT PLAN,.ON REVERSE SIDE <br /> OR DEPARTMENT USE ONLY } <br /> PHASE IiN <br /> .-DATE <br /> APPLICATION ACCEPTED B } <br /> ADDITIONAL COMMENTS: PHASE III/FINAL INSPECTION <br /> PHASE II GROUT INSPECTION = <br /> ATE INSPECTION BY ,� _ DATE <br /> INSPECTION BY r <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. 4/72 IMS <br /> E H 1426 z <br /> i <br />