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[t f•,,,R. . .-..L-.._.ki <br /> / SAN, JOA,QUIN LOCAL HEALTH DISTRICT <br /> �K z.. V/11601OF ICE USE: E. Hazelton Ave. , Stockton, Calif. <br /> ¢` <br /> Telephone: (209) 466-6781 pVA <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.1'7 <br /> THIS PERMIT EXPIRES 1 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 herezn 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 /> 1�r0Z_ <br /> .SOB ADDRESS/LOCATION az bAllur- ' CENSUS TRACT - <br />�r <br /> . er's .Name aA Phone 2'75 <br />"'Address (�, Ci ty , <br />,-Contractor. shame <br /> ,( �. License "# ff �Phone " 7 <br /> o�5'Z7 i <br /> z <br /> TYPE OF WORK (Check). ;NEW WELL /�:KD EEPEN /_/ RECONDITION / / DESTRUCTION <br /> . PUMP INSTALLATION / / PUMP REPAIR "/ / PUMP REPLACEMENT /7 <br /> Other '/ / <br /> DISTANCE TO NEAREST: SEPTIC TANK p© SEWER LINES PIT PRIVY <br /> SWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industria]. Cable Tool Dia. of Well Excavation <br />.j Domestic/private' : Drilled Dia. of Well Casing �r _ <br /> ` Domestic/,public 1 Driven Gauge of Casing ' <br /> °�/ Irx, gatio'n �/ Gravel, Pack Depth of Grout Seal <br />,F Other 4 Rotary . Type of Grout <br /> I Other Other Information ���g fj — fjca.uLc�7iP <br /> PT-MP INSTALLATION:_ Contractor <br /> f9z. Type of Pump H.P.i <br /> 4 <br /> Y fix I <br /> Pte. REPLACEMENT..--- - .--/:7—State= Work-Donee <br /> P 1I' "'tEPAIR: / / State Work Done <br /> Tj <br /> ,DFIZTRUCTION OF WELL: " 'Well Diameter x� Approximate Depth <br /> Describe Material and Procedure <br /> 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 well ''construction. Within FIFTEEN DAYS <br /> after completion of qty work on a new well, I will furnish the San Joaquin Local Health District a <br /> 14ELL DRILLERS REPORT of the well and notify them before putting the well in use. The aboye <br /> information is true to the best of my knowledge and belief. <br /> SIGNED ` <br /> ' r C�GIC:��i 0"()CJ r.�z <br /> � TITLE <br /> {D OT, PLAN ON REVERSE SIDE) <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> - <br /> APPLICATION ACCEPT4 BY DATE <br /> ADDITIONAL COi FUT <br /> INSPECTION PHAS ;4IjfINAL INSPECTION <br /> INSPECT DACE — - - INSPECTION BY DATE . I <br /> CALL FOR A GROUT INSPECTION PRIOR TO GR TING AND FINAL. INSPECTION. <br /> r� E-H .1426 ff/7'4 <br />