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�.. +'•+k'W �6 .�:h' _ _ :sir, °. . <br /> SAN JOAQUIN LOCAL HEALTH D19TRICT x <br /> FOR'OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466--6781 <br /> APPLICATION FOR'VELL .CONSTRUCTION OR PUMP PERMIT Permit .No. <br /> THIS PERMIT5" 1° YEAR FROM DATE ISSUED Date Issued. <br /> \' (Complete. In -T'riplicate) <br /> Application is hereby made - o the San Joaquin Local Health District for a permit to construct ' <br /> and/or'install the work herein described. .. This application i.s•;made in compliance .with San Joaquin <br /> County Ordinance No. 1.862 acid the Rules and` Regulations of the' Sari ,Joaquin Local Health District. <br /> 'JOB ADDRESS/LOCATION L� (Y ',N' CENSUS TRACT <br /> Y <br /> Owner's Name q� C� /"':'r ��"c !� � Phdhe <br /> x Address =City <br /> /I�//� a_ ��G p <br /> e <br /> Contractor's \Name / �7I' {� `��Jt -License <br /> TYPE OF WORK (Check): NEW WELL / DEEPEN /7 RECONDITION /_7 DESTRUCTION <br /> 3, PUMP]INST LATION / / PUMP REPAIR / ./- PUMP REPLACEMENT /7 <br /> Other <br /> i � <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES J�_ L PIT PRIVY 'f• <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL "CONSTRUCTION SPECIFICATIONS <br /> Industria- gmf Cable Tool Dia, of Well Excavation <br /> 7rpomesti.c/�rivat9' Drilled Dia, of Well Casing � <br /> Iy <br /> Domestic/public Driven Gauge .of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other -Rotary Type of Grout � Dl <br /> Other Other Information <br /> f-„ <br /> PUMP INSTALLATION: Contractor <br /> Type !of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work. Dane <br /> PUMP REPAIR: / / ,State Work Done <br /> ,DESTRUCTION OF WELL: Well Diameter Approximate"' Depth -- ' <br /> ...VDescribe Material and Procedure <br /> „.1 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 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 above <br /> information is true to the best of my kn6w1iidge and belief. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE ' <br /> FOR DEPARTMENT USE ONLY _ <br /> PHASE I i <br /> APPLICATION ACCEPTED BY DATE �� 3 <br /> -ADDITIONAL COMMENTS: <br /> PHASE II GROUT ,INSPECTI N PHA$E 441/FINAL INSPECT ON <br /> INSPECTION BY -DATE INSPECTION BY 4 kNkA I DATE` 3 <br /> CALL FOR A UT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTI0N&: ,:. <br /> E H 1426 w y - 7/72 IM QD <br />