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SAN JOAQUIN LOCATE HEALTH DISTRICT <br /> FOF.*:OFkICE USE:. 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. - �3? <br /> -- THIS PERMIT 'EXPIRES 1 YEAR FROM DATE ISSUED Date issued <br /> .(Complete In Triplicate) <br /> ion is hereby made to the San Joaquin Local Health District for a permit to construct <br /> Applicat <br /> and/or install the work herein described. , This application is made in compliance with San Joaquin <br /> No. 1862 and the Rules and Regulations of the San Joaquin. LocalItea.l.th District, <br /> County Ordinance „_} : vS! L, -0/ <br /> :0-;Y.. ,5[_L-r o A-CLA. [�jet NSU S TRACT , <br /> JOB ADDRESS/LOCATION <br /> Phone <br /> Owner's Name a� <br /> k <br /> Cityf <br /> Address <br /> ricense hon <br /> *Co�tr�t.'tor's Na�ie•" <br /> TYPE OF WORK-(Check): NEW WELL / DEEPEN / I RECONDITION I I DESTRUCTION <br /> 1 i PUMP IN TION I Pv'T`'� REPAIR'/ / PUMP REPLACEMENT 17 <br /> [ Other / I ..• a <br /> DISTANCE TO NEAREST: SEPTIC TANK 3 f PIT, PRIVY <br /> SEWAGE DISPOSAL FIELD �CESSPOOL/SEEPKGEfPIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> ! Iindustri.al Cable Tool Dia. of Well Excavation <br /> Drilled Dia. of Well Casing <br /> Domestic/private <br /> ` Driven Gauge 61„Casing .. , <br /> t Domestic/public <br /> Irrigation Gravel Pack Depth of•Grout Sea] , <br /> \other Rotary Type of ,Grout _ Y <br /> S <br /> Other Other Information' - <br /> PUMP-INSTALLATION: Contractor H.P.'" ` <br /> Type of Pump t k'�- � � <br /> PUMP*REPLACE^MENT: / / State Work .Done <br /> F � �..." ,..State Wore - - - _ <br /> r PUMP '2EPAIR:�+- / / <br /> Approximate Depth <br /> DFgTRUCTION OF WELL: Well Diameter - <br /> ' Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the Sari Joaquin Local Health District <br /> and .the State of California_pertaining.Tto_or_,regizlating_ well "construction. Within FIFTEEN DAYS <br /> ' after completion of my work an a new well, I will furnish the -San Joaquin Local Health District : <br /> { WELL DRILLERS REPORT of .the we and notify them: before putting the well in use. The above <br /> information true to the a of my, knowledge and belief. <br /> / TITLE _ o . <br /> SIGNED' ` 4V�011 � <br /> PLAN ON REVERSE SIDE) <br /> DPARTMENT USE ONLY <br /> P ' <br /> PHASE I i DATE L'. ;2-- <br /> Z <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COINDSENTS: <br /> PHASE II GROUT INSPECTION �' ►` PHASE III/FINAL INSPECTION <br /> INSPECTION BY <br /> MATE - - INSPECTION BY DATE - <br /> . , CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. - 5/,/3J611 <br /> 1101_ <br />