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J SAN JOAQUIN LOCAL HEALTH DISTRICT a <br /> FO£. OIPICL USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No 71;' <br /> Date Issued .,J-7t7 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED �---- <br /> (Complete In Triplicate) permit ka construct <br /> Application is hereby made to the San Joaquin Local Health District for a p <br /> and/or install the work herein described. ' This application is de in compliance with San Joaquin : <br /> and Regulations of t an Joaquin Local Health District. <br /> County Ordinance No. .186.2 and the <br /> CENSUS TRACT ' <br /> ,/ �r�f � } <br /> JOB ADDRESS/LOCATI N <br /> Phon <br /> r s Name �• ��� �,�.CJT"�� e <br /> Owner's <br /> ' �J City �d � <br /> Address <br /> License �6' 30'23 Phone <br /> Contractor's Name <br /> STRUCTION /-7 <br /> TYPE OF WORK (Check) : NEW WELL '/—/ DEEPEN '/ / REC{)NDITI pUMPEREPLACEMEN- -7 <br /> PUMP INSTALLATION / / PUMP REPAIR /� <br /> Other ./ / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER ' <br /> L <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS . <br /> f Industrial -- Cable Tool Dia. of Well Excavation O <br /> Domestic/private Drilled' ;;,. Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation _ Gravel Pack Depth of Grout Seal ` <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor H.P. <br /> .Type of Pump <br /> PUMP REPLACEMENT: / / State Work Done <br /> - - x State Work D --1�.• - <br /> PUMP 'tEPAIR c °� / <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 San Joaquin Local Health District <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 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 /> G <br /> TITLE <br /> SIGNED �d-n <br /> RE <br /> (DRAW PLOT PLAN ON VERSE SIDE} <br /> FOR DEPARTMENT USE ONLY <br /> PHASE,I DATE <br /> - � ; <br /> PHASE II � <br /> APPLICATION ACCEPTED -BY <br /> ADDITIONAL COMMENTS: I/ <br /> ROUT I ECTION P T NAL INSPECTION <br /> DAT Q- vim <br /> INSPECTION BY DATE INSPECTION B <br /> .. GALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> - IT , J.A 4 -- <br />