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it <br /> i' <br /> SAN JOAQUIN LOCAL iiEALTH DISTRICT <br /> ri'. OF1 ICS. USE: �' 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (.209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.. /-7 3_Z� <br /> THIS PERMIT EXPIRES 1 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 /> k and/or install the work herein described. , This application is made in compliance with San Joaquin <br /> ih r <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local health District. <br /> JOB ADDRESS/LOCATION �._- � CJS � �J CENSUS TRACT <br /> III <br /> Owner's Name —j (J t K-10 Phone% �' <br /> Address 4 6 � r � -(�. /l� ._ - cit <br /> y <br /> Contractor's Name ,f Q t, , , �, License. # Phone <br /> TYPE OF WORK (Check) :I ! NEW WELL I I DEEPEN '/% RECONDITION I l DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR . PUMP REPLACEMENT /- <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial �� Cable Tool' Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing - - <br /> Irrigation► Gravel. Pack Depth of Grout Seal <br /> Other Rotary Type. of Grout <br /> IM Other Other Information ' <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP 'tEPAIR: � State Work Donees ,/ ` 9z <br /> ,DF�TRUCTION OF WELL: Well Diameter Approximate Depth <br /> - -- , , Describe Material and Procedure <br /> I hereby agree to col ly with all laws and regulations of the San Joaquin Local Health District <br /> F 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 REPORTof the well, and notify them before putting the well in use. The above <br /> information is true to the best of my knowledge and belief. <br /> SIGNED . TITLE ay .G 6J...-, <br /> �G (DRAW PLOT PLAN ON REVERSE SIDE) <br /> J� FOR DEPARTMENT USE ONLY <br /> PHASE I J �7 <br /> APPLICATION ACCEPTED ..8Y DATE / <br /> ADDITIONAL COMMENTS: <br /> PHASE IIAPGROUT INSPECTION PIJASE, /FLN INSPECTION <br /> INSPECTION BY IN' DATE INSPECTION B g DATE <br /> - <br /> CALL -FOR A GROUT ASPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 N 5/731M <br />