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�tA�A w 1&wmPjj Rc�) �F«w-v,- CwY <br /> L' SAN JOAQUIN LOCAL BEALTH DISTRICT <br /> 1CkFUSE: �xZ1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No,�. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued g:1 7 7727- <br /> (Complete In Triplicate) <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 Joaquin <br /> County Ordinance No. 1862 and the Rules nd Regulotions of the San Joaquin Local Heal h District. <br /> JOB ADDRESS/LOC T ON <br /> Owner's Name. /`- Phone/ <br /> City <br /> Address _ <br /> Contractor's Name � g License �J��honeggt' <br /> TYPE OF WORK (Check): NEW WELL/ / DEEPEN/ / RECONDIT _ l�/ DESTRUCTION /- <br /> PUMP INSTLATION P111MP REP R EMP REPLACEMENT /� <br /> AL <br /> Other l / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial ,,x--Cable�T6ol' Dia. of Well Excavation <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 `s Other Information - <br /> -j <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump 4< H.P. <br /> PLW REPLACEMENT: i / State Work Done <br /> .-�.....,.-,�..��..��T.. State Work Do - <br /> PUMP "tEPAIR: r <br /> E.' r Appr ximate Depth <br /> DFRTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure 4 <br /> I hereby agree to comply with all law= and regulations oflthe San Joaquin Local Health District <br /> and the State of California pertaining to or r'egulatingiyell 'construction. Within FIFTEEN DAYS <br /> after completion of my work on a new swell, I wiil•furnish'.,the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notify them before putting the, ell is use. The above <br /> information is true to the best of my knowledge and belief. ` <br /> SIGNED /�' ` TITLE C1 r + <br /> (DRAW PLOT PLAN ON REVERSE SIDT) 7 <br /> JOR DEP.ARTMENT USE ONLY , <br /> PHASE I t �. DATE " .� <br /> i APPLICATION ACCEPTED .B <br /> ADDITIONAL COMMENTS: <br /> PF S II GROUT INSPECTIaN PHA I FINAL INSPECT ON <br /> r- INSPECTION BY DATE INSPECTION BY DATE �" S <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPE ION. <br /> 5/73 IM' <br />