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ry <br /> L SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF. OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephoner (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> 79 /60-ice <br /> THIS,rPERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> r 3s' ✓`'�(/ S ct1t ;�.' {Complete In Triplicate.} po7 a7�-. as <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 Sa:n Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the Sari Joaquin Local. H.eal.th District. <br /> JOB ADDRESS/LOCATION �les f? !, CENSUS TRACT - <br /> ay <br /> owner's Name N Phone <br /> Address city, J <br /> S f <br /> Contractor's Name ! License 4��� Phone <br /> t S _ <br /> TYPE 'OF WORK (Check): � NEW WELL DEEP '/ / RECONDITION_/ / DESTRUCTION /— <br /> �, YUMP INSTALLATION � PUMP REPAIR'/ / PUMP REPLACEMENT /? <br /> Other 1 / <br /> DISTANCE TO NEAREST: SEPTIC TAiJK #-"SEWER'LINES PTT-, PRIVY` ' <br /> -SEWAGE DISPOSAL 'FIELD CESSPOOL/SEEPAGE PIT 1 OTHER <br /> . . - <br /> INTENDED USETITPE OF WELL CONSTRUCTION SPECIFICATION <br /> IndustrialCable Tool - Dia, of WeZl­%�Excavation <br /> Domestic/privateoi Drilled Dia. of Well Casing � <br />` Domestic/public Driven GaugelFof Casing, : <br /> Irrigation ;' Gravel. Pack Depth of.Grout, Seal'4-:- <br /> Other - Rotary Type of Grout,` <br /> ' .;_. Other Other Information <br /> PUMP INSTALLATION: ,!Contractor C <br /> - `'Type of Pump H.P. 1 <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP. 'tEPAIRtate.-Work.,Done.. <br /> DF'-TRUCTION OF WELL: ""Well Diameter Approximate Depth <br /> ;i-Describe Material and Procedure <br /> I <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 . ERS REPORT of .the well and notify them before putting the in use. The above <br /> infor ion 's tr t the best of my knowledge and belief. <br /> i <br /> SIGNED �` TITLE <br /> 11 (DRAW PLOT PLAN ON REVERSE SIDE} <br /> i� FOR DEPARTMEJJT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED .�Y DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II ,GROUT INSPECTION, PHASE III/FINAL INSPECTION , <br /> INSPECTION BY r > DATE "` .741 INSPECTION BY �'f -_. DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO•GROUTING A14D,JINAL. INSPECTION. - <br /> U IA?A P <br />