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V�- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF. Oi'NICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> �_. Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUTS' PERMIT Permit No. <br /> THIS PERMIT EXPIRES I 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 /> co 0J <br /> ,TOB ADDRESS/LOCATION �2 �'7 C �� U C CENSUS TRACT ' <br /> Owner's Name (.J Y►1 . Phone <br /> Address <br /> City _ L�S'.G �1 �.. O AJ <br /> Contractor's Name S License X71 Phone pa <br /> i <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN ,/—/ RECONDITION /_/ DESTRUCTION /? <br /> AL <br /> PUMP INSTLATION PUMP REPAIR'/ / PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK d0 SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> A <br /> INTENDED USE TYPE.-05. WELD CONSTRUCTION SPECIFICATIONS <br /> Industrial Y s°"; -- X 'Cable,.y,Too1 Dia. of Well Excavation <br /> L _ _ Dame,stic/prime- - `mac Dri1];ed - _T Dia.`61 Well Casing 12 b • _ <br /> ,\v <br /> Domestic/public Driven Gauge of Casing \ , <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other �T�. Rotary Type of Grout <br /> Other Other Information <br /> .PUMP INSTALLATION: Contractor - <br /> s <br /> ;Type of <br /> Pump-H.P. <br /> PUMP REPLACEMENT: / J ;State Work Done ` 6 <br /> PUMP UPAIR: /7 7 State Work Done =?. <br /> .DFgTRUCTION,.OF ,.WELL: Well Diameter Approximate Depth <br /> Describe 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 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 /> informatio is true to the best ofm knowledge and belief. <br /> } <br /> SIGNER 1�_ _ C7a�-•A-X TITLE �7 A 5/,77 *A <br /> (ORAW PLOT PLAN ON REVERSE SIDE) <br /> FOR D T USE ONLY <br /> PHASE I <br /> rAPPLICATION ACCEPTED BY '41e DATE Z # <br /> ADDITIONAL C0101ENTS: <br /> PHAS5 11 GROTf INSPECTION PHASE IIOIWL INSPECTION Z <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> i <br /> { CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL IN 'TION. <br />