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f <br /> i /� _ <br /> �/ SAN JOAQUIN LOCAL ,HEALTii DISTRICT <br /> FF, . OFFICE USE: 1601 E. Hazelton .eve. , Stockton, Calif. <br /> f* Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP ]HERMIT Permit No. �ff_f�4p <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued <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 and Regulations, of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATIONZ - y-��f - - CENSUS TRACT <br /> Owner's Name —L.Cr �:s�a._ 'd t 4 Phone <br /> r. <br /> ' Address -/ C? - �X City <br /> Contractor's Nameo�, �ra.rs' 1 r��Cik� License x7 Phones'.�s4 �~ <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN ] / RECONDITION / / DESTRUCTION /7 <br /> PUMP INSTALLATION X/ PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other / / 'I: <br /> 7— <br /> DISTANCE <br /> DISTANCE TO NEAREST: SEPTIC TANK /fid SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation " C <br /> Domestic/private Drilled Dia. of Well Casing -- - - <br /> Dome`s'tic/public Driven`- ` Gauge of Casing <br /> Irrigation ` Gravel. Pack Depth of Grout Seal <br /> Other - Rotary Type of Grout T C:A-Z *4C ^ <br /> Other Other Information <br /> Q <br /> PUMP INSTALLATION: tdntractor <br /> } Type of Pump H.P. <br /> PUMP REPLACEMENT: r/> State Work Done <br /> PUMP nPAIR: - f / State Work Done - �-- <br /> t - <br /> DFgTRUCTION OF WELL: .Wel.l. Diameter _ ` • Approximate Depth <br /> Des-cribe 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;we_ll 'cdnstruction. 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 abovg <br /> information, is true to the best of my knowledge and belief. ,�/�- <br /> SIGNED C.! TITLE ��vv <br /> �7kt1 <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> d PHASE I <br /> APPLICATION ACCEPTED .BY C. DATE P-I P- 21 <br /> ' ADDITIONAL COMI1 ENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE. -- <br /> CALL FOR GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTIO47 �G_�`el <br /> EH 1426 5/731M <br />