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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> OFF 1601 E. Hazelton Ave. , Stockton, Calif. <br /> FIFO—F."01 USE: <br /> Telephone: (209) 466-6781 Permit No. l/ <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT _.L� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Date Issued <br /> (Complete In Triplicate) permit to construct <br /> Application is hereby made to the San Joaquin Local Health District for a p <br /> is install the work herein described. * This application is made in compliance with San Joaquin <br /> and/ <br /> Dunt Ordinance No. 1862 and the Rules and ReSll�lat pTLVF,1 RO 1- mmiz` Local Health District. <br /> County v 'r! 6F AR0K f o G aN <br /> .$ .+ �.1�`\ ,t'�C CENSUS TRACT <br /> JOB ADDRESS/LOCATION <br /> Phone - <br /> owner's Name /l <br /> city LDrD 1 <br /> Address � e V ` +�t <br /> L►M License # 21TIna Phone <br /> Contractor's Name d ►fl P 20 � i�l �-L �� --- <br /> DE / / RECONDITION / DESTRUCTION /7 <br /> TYPE OF WORK (Check): NEW WELL lkoorP�*Mp REPAIR / / PUMP REPLACEMENT L-7PUMP INSTALLATION / I <br /> Other / / <br /> SEWER LINES PIT PRIVY <br /> DISTANCE TO NEAREST: SEPTIC TiuvK CESSPOOL/SEEPAGE PIT OTHER <br /> SEWAGE DISPOSAL FIELD <br /> T�'PE OF WELL CONSTRUCTION SPECIFICATIONS <br /> INTENDED USE Cable Tool Dia. of Well Excavation <br /> Industrial --� Drilled Dia. of Well Casing <br /> Domestic/private _ <br /> Driven Gauge of Casing <br /> Domestic/publicGravel Pack Depth of Grout Seal <br /> r� Irrigation RotaryType of Grout <br /> Other <br /> Other Other Information <br /> PUMP INSTALLATION: C6ntractor ► H.P. <br /> Type of Pump <br /> PUMP REPLACENH;NT: / <br /> State Work Done <br /> PUMP': 'tEPAI : L-1Approximate <br /> Work Done <br /> R Approximate Depth <br /> DFqTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure <br /> rict <br /> agree to comply with all laws and regulations of ll construction.San Joaquin L 'Withiu FIFTEENocal Healt DAYS <br /> I herebya g regulatingwell <br /> and the State of California pertaining to or will furnsh the San Joaquin Local health District a <br /> after completion of my work on a new well - putting the well in use. The above <br /> WELL, DRILLERS REPORT of the well and notify them before p g <br /> information is to the best"Oy nowledge and belief. <br /> TITLE <br /> SIGNED (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY nn <br /> PHASE I DATE <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: PHASE III/FINAL INSPECT ON <br /> PHASE II GROUT INSPECTION <br /> INSPECTION BY <br /> DATE INSPECTION BY <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. 5/731M. <br /> - - 11 1.'l G - _ <br />