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' 0J <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT al �{qor.,:OF E <br /> d- <br /> USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> 3- 4l <br /> -4 Telephones (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 1*1 x{43 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued o `� <br /> (Complete In Triplicate) <br /> 1 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 San Joaquin <br /> County Ordinance .No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> i Owner's Name �/zr2 T I t T C-!� Phone 1 <br /> Address �' City <br /> ` Contractor's _Licensejl , " ,,Phone <br /> TYPE OF WORK (Check); NEW WELL-&7t- DEEPEN--,j /_ -RECONDITION / /� DESTRUCTION <br /> ` PUMP INSTALLATION "PUMP►�REPAIR; lel :PUMP REPLACEMENT 1�T <br /> Other / / f <br /> DISTANCE TO NEAREST: SEPTIC TANK �-T. ~SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER 6 <br /> INTENDED USE TYPE Ok'' WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial ` V'.1Cable Tool Dia. of Well Excavation ' <br /> Domestic/pra, <br /> �`..vat-`-_`_'e Dr-3.11-ed Dia. of Well Casing, <br /> _ Domestic/public Driven Gauge Gauge of Casing ! r <br /> f Irrigation Gravel Pack - `Depth of Grout Seal <br /> f Other Rotary Type of Grout <br /> Other OtherN-Information ' <br /> PUMP INSTALLATION: Contractor <br /> of-Pump -- }{ H.F. ' 1 <br /> PUMP REPLACEMENT: State Work bone <br /> _ . v <br /> - /T/—State`Work Doke <br /> DF- 'RUCTION OF WELL:�,Well_.Diameter L Approximate Depth'` <br /> Describe Material and Procedure : ° <br /> I hereby agree to comply, with a1.1 laws and regulations of the San Joaquin Local Health District <br /> 1 and the Statet.of Califo�'nia pertaining to or regulating well "Construction: Within FIFTEEN DAYS <br /> ` after completion offm work on a new well, I will furnish the Sari <br /> p Y -JoaquiniLocal Heaith District + <br /> WELL DRI EPORT of tYie well and notify theml before putting the well in use. The above <br /> informati is rueto e est of my knowledge and belief. <br /> 1 M <br /> i f <br /> S � ' TITLE <br /> SIGNED <br /> (DRAW PLOT PLAN ON REVERSE SID <br /> FOR DEPARTMENT USE ONLY � <br /> s PHASE I DATE-dp==��b-17 <br /> IO <br /> APPLICATN__ACCEP_TED-BY�. -- <br /> { ADDfTiONAL COMMENTS <br /> PHASE I ROUT INSPECT N I- PEiAA III/ INAL INSPEC <br /> INSPECTION BY DATE 'INSPECTION, ICY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. .5731 <br />