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�'d•N JOAQUIN LOCAL HEALTH <br /> DISTRICT <br /> zelton Ave. ,FOR OFFICE USE: 16x1 E. nh� Stockton, Calif, <br /> Teleph -e' (209) 466-6781 <br /> k APPLICATION FOR WELL .3TRUCTION OR PUMP PERMIT <br /> Permit No. -O 1z/ <br /> L � <br /> THIS PERMIT EXPIRES 1 YEr`. FROM DATE ISSUED. Date Issued <br /> (Complete In In Trip- .icate) <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 San Joaquir <br /> County Ordinance No.= 1862 ar,id the Rules and Regulations of' the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION �•- CENSUS TRACT <br /> Owner's Name <br /> Contractor s Address_131 7j License No C,23,,Z 3 Phone <br /> f: <br /> Contractor's Name Livens C3Phone 7 <br /> t TYPE OF WORK (Check):. _NEW_1%TELL DFPEN / / RECONDITION_/_ --.;DESTRUCTION. • - � <br /> E ' PUMP INSTALLATION'/ / PUMP REPAIR / / PUMP REPLACEMENT <br /> { Other <br /> DISTANCE' TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD y CESSPOOL/SEEPAGE PIT OTHER <br /> IN ENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Imo-✓'Cable Tool Dia, of Well Excavation \ <br /> r dl--60mestic/private I Drilled Dia. of Well Casing <br /> Domestic/public 1 Driven Gauge of Casing <br /> Irrigation I Gravel Pack Depth of Grout §kal <br /> Other <br /> }I Rotary Type of Grout <br /> A Other Other Information k• <br /> k <br />{ <br />,.PUMP INSTALLATION: ContraltorCQ <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State.Work bone <br /> PUMP REPAIR: / / State Work Done }'' ^ <br /> .PESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure - <br /> I <br /> I hereby agree to comply withiall laws and regulations of the San Joaquin Local Health District <br /> land 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 a <br /> WELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br />' information is true to t e best of my knowledge and belief. <br /> SIGNED �'j TITLE j <br /> 1 (DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE I FOR DEPARTMENT USE ONLY -- - - — 11 <br /> APPLICATION ACCEPTED BY '1 <br /> - ' DATE /aZ Q <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTIO PHASE I FINAL INSPEC ION <br /> INSPECTION BY gW DATE i INSPECTION BY DATE j 5 <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 <br /> s 7 17 0P 1 t.r <br />