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SAN JOAQU-1N LO-CAL HEALTH DISTRICT <br /> 70F. OFIRE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> 417 <br /> - Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. S-�9 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 2 L:Zj <br /> (Complete In Triplicate) ,.�� <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 Sart Joaquin <br /> County Ordinance No. 1862 and t � ltd Remtions of the San Joaquin Local. Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name Phone <br /> Address d1140e „� �+ J� City <br /> Contractor's Name �` ��. License i Phone 4 <br /> TYPE OF WORK (Check) : NEW I-TELL / / DEEPEN '/ / RECONDITION /_/ DESTRUCTION /-7 <br /> &PUMP INSTALLATION PUIQ REPAIR / J PUMP REPLACEMENT /7 <br /> Other lee c», .�► <br /> 000, <br /> DIST&NCE TO NEAREST: SEPTIC TANK SEWER LINES PIT 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 /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing y <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout y <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor U S <br /> Type of Pump .P. <br /> _ f <br /> PUMP REPLACEMENT: / J State Work Done <br /> PUMP 'tEPAIR: / J State Work Done <br /> .DFRTRUCTION 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 Distric <br /> 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 <br /> WELL DRILLERS REPOR e well and notify them before putting the well in use. The above <br /> inform my knowledge and belief. t <br /> SIGNED TITLE <br /> DRAW PLOT PLAN ON REVERSE SID <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY _ DATE,, ' <br /> ADDITIONAL COMMENTS: "```����''''"'' L <br /> PHASE II GROUT INSPECTION PHASE II FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY Z, 'C '- DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br />,� _ E H 142_ - <br /> 5/73!?K <br />