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FOR SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> OFFICE USE: .1601 E. Hazelton Ave. , Stockton, Calif. <br /> d 11'ITelephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR- PUMP PERMIT Permit No. <br /> OFFICE <br /> �� � <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Date Issued �i���J <br /> ation is hereby made to the <br /> San Joaquin Lo al Health Districtrtconstruct <br /> a permit <br /> ` and/or install the work herein described. This application is made incompliance ApplicJoaquil <br /> County Ordinance No, 1862 and the �Rules and tions of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION � II <br /> _// ad CENSUS TRACT <br /> Owner's Name Ge' ter'✓! . �j41-0t;� <br /> !� <br /> Phone <br /> Address <br /> �I City <br /> Contractor's Name <br /> License # <br /> TYPE OF WORK (Check) : NEW WELL I I. DEEPEN- -- -- <br /> . -.RECONDITION /_7 DESTRUCTION /? <br /> PUMP INSTALLATION / _PUMP- REPAIR / PUMP REPLACEMENT /7 <br /> Other <br /> II <br /> DISTANCE TO NEAREST: SEPTIC TANK II-1_ SEWER LINES <br /> SEWAGE DISPOSAL FIELD PIT PRIVY <br /> li CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED . _S TYPE OFI WELL <br /> Industrial ' CONSTRUCTION SPECIFICATIONS <br /> Cable Tool Dia, of Well Excavation <br /> Domestic/private Drilled <br /> Dome s`t l�/,public Driven Dia.- of Well Casing a <br /> Irrigation" '_ �- Gauge of Casing <br /> Other Gravel..Pack - Depth- of- Grout Seal ;y r,_• <br /> Rotary Type of-Grout <br /> Other <br /> ..��� Other Information F <br /> INSTALLATION: �~ <br /> Contractor <br /> Type of PumpP. <br /> PUMP REPLACEMENT: " <br /> State W II k Dane �, 8 //� <br /> .i <br /> PUMP REPAIR: + <br /> / / State Work Done <br /> ESTRUCTIAN OF WELL.: Well Diameter .�l. ro: <br /> Describe Material and procedure A PP ximate Depth <br /> II �� <br /> I hereby agree to comply with all lavas and regulations of the San Joaquin Local Health bistrict 1 <br />.and <br /> completion of my work and the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br />•=aon a newtwell, 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 m knowledge-and belief, <br /> SIGNED <br /> TLE <br /> W PLAT PLAN ON R V• R S E <br /> _SI <br /> PHASE I I FOR DEPARTMENT USE ONLY <br /> APP LICATION ACCEPTED,BY <br /> ADDITIONAL COMMENTS: ` DATE <br /> PHASE II GROUT INSPECTION � <br /> INSPECTION BY PHASE II FINAL INSPECTION <br /> DATE 1 _ _` INSPECTION BY �ewf_ 2 <br /> DATE <br /> CALL FOR A GROUT .INSPECTION PRIOR TO GROUTING AND FINAL INSPECTI ✓d <br /> E .H 1426 ! � <br /> 7/72 1M '� <br />