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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> �) Calif. <br /> " �v 601 E. Hazelton Ave, , Stockton, <br /> i <br /> a�FOR OFFICE USE: Telephone: (209) 4666781 Permit No. <br /> PERMIT <br /> APPLICATION FOR WELL CONSTRUCTION OR Pump <br /> Date Issued ,� S <br /> THIS PERMIT EXPIRES 1 YEAR <br /> FROM DATE ISSUED I� <br /> (Complete In Triplicate) permit to construct <br /> d, This application is made in complocaleHealthSan <br /> Districn <br /> kation is hereby made o the San eoaquin Local Health District for o L <br /> Application uir <br /> and/or install the work her in d�=scrib ulations of the San Joaq <br /> Count Ordinance No. 186'2 a d the Rales and Reg CENSUS TRACT <br /> County <br /> l <br /> JOB ADDRESS/LOCATYON 2 Phone <br /> owner's Namer <br /> City <br /> 1 Addresshone <br /> ' <br /> License #k lyp0 Y <br /> I Contractor's Name i <br /> f _ DESTRUCTION /-7 <br /> ' DEEPEN I I RECONDITION_/� <br /> r TYPE OF WO1tK (Check) : NE W�l / I PUMP REPLACEMENT I-77 <br /> k <br /> PUMP INSTALLATION: I___.IW,a.PUMP REPAIR / / t <br /> k <br /> Other <br /> SEWER LINES , PIT PRIVY <br /> IC TANK. CESSPOOL <br /> PIT OTHER <br /> 1 DISTANCE TO NEAREST: SEP <br /> SEWAGE DISPOSAL FIELD ___._-- <br /> ' . CONSTRUCTION SPECIFICATIONS <br /> t INTENDED USE TYPE OF WELL <br /> Cable Tool Dia. of Well Excavation <br /> ' Industrial Drilled Dia. of`Well Casing "' <br /> ' - Domestic/private II <br /> Driven Gauge of Casing J <br /> Domestic/Public- :: Depth of Grout Seal. <br /> I Irrigation Gravel Pack ,. P <br /> Rotary Type of Grout. <br /> Other Other Information <br /> —r—�-- Other <br /> � f r <br /> PUMP INSTALLATION: Contractor H.P. 11 / JI <br /> T pe of Pump i <br /> PUMP REPLACEMENT` / / State Work Done fdf i <br /> PUMP REPAIR: J / State Work Done : <br /> Approximate Depth l <br /> ESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure <br /> T hereby agree to compl with all laws and regulations of the San Joaquin Local Health Disti`ict <br /> y <br /> and the State of in FIFTEEN DAYS <br /> Califo nia pertaining to °I willegulfurnishethecSantJoaquin.LocalhHealthh Dist ict <br /> C after completion of my work on a new well, <br /> WELL DRILLERS REPORT of the well and notify them before putting the well in use. The: above <br /> r information is true to the best of kno die- d belief. ° <br /> r' ITLE <br /> SIGNED i1 <br /> D LOT PLAN ON R iYSE SIDE <br /> FOR 'DEPARTMENT USE ONLY <br /> PHASE I DATE fly- i <br /> APPLICATION ACCEPTED: BY <br /> ADDITIONAL COMMENTS: PHASE III FINAL INSPECTION <br /> PHASE II GROUT INSPECTION= INSPECTION BY. DATE <br /> INSPECTION BY DATE <br /> CALL FOR A GROUT .INS ECTION PRIOR TO GROUTING AND FINAL INSPECTION. 7172 114 <br /> E H 1426 <br /> , it M <br />