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_ SAN J'OAQUIN LOCAL-HEALTH DISTRICT , <br /> FOS'. ,FT USE: � . 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 ' <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Per <br /> No. _ �{ <br /> THIS PERMIT EXPIRES 1. YEAR FROM DATE 'ISSUEDDate .Issued <br /> :;0AE r 4a 77-4 J, -.. <br /> {Complete In Triplicate) Zoe- f�o�Z7 <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. i <br /> JOB ADDRESS/LOCATION - / NSUS.TRACT - <br /> Owner's Name - .J� ill ? 1 • _ Phone <br /> 1:2 <br /> Address . f City i <br /> kAv. ..�Licez�se ,��e_ d' Phone <br /> Contractot'�s 'Name - - - � -, - -1 <br /> ? 10 �. . <br /> TYPE OF WORK "(Check) : NEW WELL /7r DEEPEN / I RECONDITION DESTRUCTION <br /> DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR / '/ PUMP REPLACEMENT <br /> Other -/_7 <br /> '' 1 <br /> DISTANCE TO NEAREST: SEPTIC TAINK SEWER- LINES PIT PRIVY + i <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER d <br /> INTENDED USE TYPE OF WELL ; CONSTRUCTION SPECIFICATIONS .,, <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled v Dia. of Well Casing <br /> F Domestic/public + Driven L0 Gauge of Casing ? <br /> Irrigation fes/_ Gravel Pack Depth of Grout Seal <br /> Other t�T Rotary (�� Type of Grout <br /> ther Other In ormation - <br /> PUMP INSTALLATION: Contractor "` "�` <br /> Type of Pump H.P. r <br /> PUMP.__REPLACEMENT: /_7 State Work Dome <br /> PUMP 'tEPAIR: / / State Work�Done , <br /> Approximate Depth <br /> pFgTRUCTION OF WELL: Well Diameter PP <br /> Describe Material and Procedure <br /> 4 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 we11 ''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 yaeli'i n Ve. The above h <br /> information is true to the 'best of my knowledge and belief. 4 � <br /> SIGNED TITLE <br /> i (DW PLOT ON REVERSE SIDE) <br /> i <br /> FOR 2EPARTMENT USE ONLY <br /> PHASE I DATE <br /> 1 APPLICATION ACCEPTED .BY <br /> ADDITIONAL COMMENTS: Le- <br /> PHASE I GROUT I SPECTION .,,,,. • '� HASE III/FINAL INSPECTION <br /> INSPECTION BY C.7 DATE INSPECTION;BY �. DATE -- <br /> . CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> TP to 7 1.')4 5/731M <br />