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.nr' -• i :f.. ,�.s �- .��:^ac.—•, 'fir s .. `� <br /> SAN JOAQUIN -LOCAL HEALTH DISTRICT <br /> Fflr.,OFl ICE USE.: ,A 1601 E. l�azelton Ave, , Stockton, Calif_ <br /> . i <br /> �� , ' Telephone: - (200' 466-678i <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. _ <br /> THIS PERMIT EXPIRES .I YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby rude 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 J,paquin¢ <br /> County Ordinance,No. .1862 and the Rules and Regulations of the San Joaquin Lscal Health District. <br /> til : 0 2-3- woo -1-51 <br /> JOB ADDRESSILOCATION, CENSUS TRACT <br /> Owner's Name Phone <br /> C <br /> Address City <br /> /Q Contractor's Name _ _ License-��chone - _ <br /> ,.� .ya..... . _ ..� <br /> TYPE OF WORK (Check) : NEW WELL � DEEPEN / / RECONDITION / /_,DESTRUCTION <br /> PUMP INST TION / J PUMP REPAIR / /PUMP REPLACEMENT <br /> Other / f i <br /> DISTANCE T NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF ELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation � { <br /> ::T�_ omestie/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 o <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done, <br /> PUMP REPAIR: l I State Work Done—' <br /> .DFO,TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> sr <br /> I hereby agree to comply with -all laws and regulations of the San Joaquin Local Health District t <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 Districtl <br /> WELL DRILLERS REPORT of the wel and notify them before putting the well in use. The above <br /> information true to the b of y kpowledge and belief. <br /> SIGNEDA) <br /> TITLE f <br /> (Paq PLOT PLAN ON REVERSE SIDE) _- <br /> FOR DEPARTMENT DISE ONLY <br /> PIiASE <br /> APPLICATION ACCEPTED -BY r DATE fd C 7 <br /> ADDITIONAL COMMENTS; � <br /> rt PHASE II GROUT INSPECTION PHASE TIT/FINAL INSPECT'IO f <br /> _ p DATE !4 77 INSPECTION BY DATE /l / <br /> INSPECTION By ' <br /> CALL FOR A GROUT INSPECTION PRIOR TO GR UTING AND FINAL INSPECTION. c <br /> 7 u I A 9 A K <br />