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FOR OFFICE 5AN JOAQUIN LOCAL HEALTH DISTRICT <br /> [ISE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> �M <br /> Telephone (209) 466_6781 <br /> T APPLICATION AFOR. WELL CONSTRUCTION OR PUMP PERMIT Permit No. I.Z, 0 <br /> THIS P�ERMMIT -EXPIRES 1 YEAR FROM DATE ISSUED <br /> � . Com Date Issued mg." - .� <br /> Application is here ( plete In Triplicate) <br /> y'made 'to the San Joaquin Local Health District for a pexmit,..to construct <br /> and/or install the work herein described. This application is made in compliance <br /> County Ordinance Na, 1862 and the"Rules 'and Regulations of the San JoaquinLocalHeat San 7aaquin <br /> Health District. <br /> JOB ADDRESS/LOCATION <br /> Ownerf 's Name �.' .. �' �, ; za <br /> CENSUS .TRACT: <br /> Phone <br /> ----------------- <br /> �i <br /> Contractor's Name ; I <br /> License # ZLZMPhone <br />', TYPE OF WORK (Check); NEW WELLRECO- <br /> / /_/ NDITION /_7 DESTRUCTION/-7 -- <br /> -- - = <br /> IPUMP INSTALLATION / / PUMP REPAIR A, PUMP REPLACEMENT 17 h <br /> Other r/ / <br />' F Lj <br /> DISTANCE Tfl NEAREST: SEPTIC ''TANK, ) <br /> SEWER LINES PIT PRIVY <br /> SEWAGE 'DISPOSAL FIELD CESSPOOL/SEEPAGE PIT <br /> ' I OTHER ' <br /> INTENDED USE TYPE OF WELL <br /> .� <br /> Ind <br /> ustrialCONSTRUCTION _SPECIFICAT <br /> ► cable Tool Dia. of Well Excavation IONS <br /> Domestic/private € <br /> Domestic i:Drilled <br /> /public Dia. of Well Casing <br /> ,[Driven Gauge of Casing <br /> .Ir Irrigation . *Gravel Pack <br /> Other Depth of Grout Seal <br /> �M � ' y Type of Grout <br /> Other <br /> Other Information i 1. <br /> �. <br /> PUMP:4! INSTALLATION: Contractor Il <br /> Type of; Pump ' <br /> ' I "- H.P. <br /> PUMP; REPLACEMENT: _ 1 .q k : <br /> i. / / St`to Work Done <br /> PUMP.,'REPAI R: t <br /> / State Work Done <br /> tj C <br /> pESTRUGTION OF WELL: Well Diameter <br /> Describe Material and Approximate Depth Procedure ------�� <br /> I hereby agree to comply with -all laws and regulations of the San Joaquin Local Heal I <br /> and the State of California �' Health Bistrict # <br /> M pgrtaining to or regulating well construction. Within FIFTEEN DAYS <br /> after completion of my work a Ia ne <br /> W&I,LhDRILLEAS REPORT of the we w well, I will furnish the San Joaquin Local Health District a i <br /> 11 and notify them before putting the well in use. The above <br /> information is true to the best of .iny knowledge and belief. <br /> SIGNED <br /> I� 4 ARAW LOT PLAN `~ TITLEr �2ifrc <br /> N REVERSE SIDE <br /> ih FOR DEPARTMENT USE ONLY <br />?HASJ I f <br /> WPLIyCATION ACCEPTED BY <br /> IDDITI"ONAL COMMENTS: DATE <br /> PHASE II GROUT INSPECTION <br />:NSPEC�TION BY .. -. '' PHA E III FINAL INSPECTION . <br /> ��. DATE INSPECTION BY (, DATE <br /> CALL-FOR A GROUT. INSPECTIONwPRIOR. TO GROUTING AND FINAL INSPECTION. -� <br /> E H 1426 <br /> ��. 7172 i m <br />