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- - - SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. � <br /> Telephorie: (209)' ,466--6787. <br /> PLICATION FOR WELL CONS TRUCTION>OR PUMP PERMIT Permit No. 2 _/ v f 5 <br /> THIS PERMIT EXPIRES 1.YEAR!FROM.DATE'SISSUED `!Date Issu/ed <br /> (Complete In Tri pli c'a e) 7 i <br /> Application`.a•isjhereby-,herebythe�San.;Joaquin Local Health Di.strict�for a,,pexmit to construct <br /> and/or install the work herein described. Thi:s':'application'-is ,made= in ,compliance with San" Joaquin <br /> County,,Ordinance SNo- ..1--862-ra-Ad�.th6-Rules.rlandz Regulat ons`of r thea San"=Joaquin-Local. Health'District: <br /> 5. <br /> ,Z2N 7 rrCENSUS TRACT S,qL F . <br /> .l'OB ADDRESS/LOCATION ; <br /> E i 'S'• '! �r2... l.i. •3 'ti, xcC°�,yY r ::5.? c"•- h. �.. }d� Fr <br /> Phone <br /> Owner's:Name'", <br /> ~ -. .- - <br /> Address �! City. . _. <br /> Contractors Name <br /> License # Phone 1f�s y7 <br /> /DEEPEN /_/ RECONDITION / / DESTRUCTION)/� } <br /> TYPE OF WORK (Check) : NEW WELL /i1 REPLACEMENT /_7 <br /> PUMP INSTALLATION "/ I PUMP REPAIR PUMP <br /> Other' /7/ — <br /> DISTANCE TO NEAREST: SEPTIC TANKJS42 2-,5 SEWER LINES PIT PRIVY <br /> SEWAGE- DISPOSAL FIELD CESSPOOL/SEEPAGE PTT. OTHER <br /> IN USE TYPE F WELL CONSTRUCTION SPECIFICATIONS • <br /> Industrial. Cable Tool Dia. of .Weld. Excavation <br /> Domestic/Private Drilled Dia. of Well Casing r r' <br /> Domestic/public Driven' Gauge of Casing <br /> Irrigation Gravel Pack ' Depth of. Grout Seal <br /> Other Rotary' Type of Grout <br /> k Other k Otheir Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P.. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done r <br /> } <br /> ,DESTRUCTION OF WELL: � We11 Diameter Approximate Depth <br /> Describe Material and Procedure <br /> 1 I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> aad 'the State of California pertaining to or regulating well construction. Within FIFTEEN,DAY.S <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 /> TITLE �( <br /> F SIGNS DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> � '- c .> a <br /> APPLICATION ACCEPTED BY DATE f" <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE II /FINAL INSPECTION. <br /> INSPECTION BY /'%� — DATINSPECTION BY DATE - ,�t ' Y <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION.—. <br /> _ . _ . ... .__ _ 4/72 1M <br />