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SAN JOAQUIN LOCAL HEALTH DISTRICT ; <br /> FOR OFFICE USE: 1601 .E. Hazelton Ave. , Stockton, Calif. <br /> w." Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCT <br /> OR PUMP PERMIT Permit No. ;LS- "/91rJ. <br /> 73-- G 3d C!J <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued'�i;1=/s-' -3^1 <br /> jf3" 5; {lrFNtrt_c / (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 Joaquinl <br /> County Ordinance .No. 1862 and the and Regulta pns of the San -Joaquin., Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT�Scm-.O /"' <br /> Owner's Name - -- Phone <br /> AddressZ11 a <br /> City <br /> I <br /> Contractor's Name (J License la3Phone ]- _' <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN /_7 RECONDITION /_7 DESTRUCTION /7 _. • .� <br /> PUMP INSTALLATION /,SUMP REPAIR / / PUMP REPLACEMENT f� <br /> AL <br /> Other / / T <br /> DISTANCE_.TO NEAREST: . SEPTIC TANK .,.SEWER LIN�S �. IT PRIVY <br /> SEWAGE DISPOSAL FIELD , -,CESSPOOL/ PIT ETHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS c <br /> �Iustrial Cable Tool Dia. of Well Excavation h <br /> omestic/private Drilled Dia. of Well Casing _ G,_ <br /> Domestic/public Driven Gauge of Casing Q <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> k Other otary Type of Grout _ , 0 i?,�,!r <br /> Other Other Information. n,-f <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H•P• /_!- ;0. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> ,PESTRUCTION OF WELL: Well Diameter Approximate Depth � - <br /> Describe Material and Procedure ' <br /> f' 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 well construction. Within FIFTEEN DAYS <br /> kafter 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 /> in ormation is true to the of my knowledge and belief. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> `PHA <br /> APPLICATION ACCEPTED BY �1241 <br /> DATE <br /> ADDITIONAL. COMMENTS: <br /> PHASZ I ROUT' INSPECTION P5WI, NAL INSPECT N <br /> INSPECTION B DATE . 17-- <br /> INSPEC N B DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> L H 1426 7172 1M' - <br />