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-- - ' r. I .- V SAN JOAQUIN LOCAL -HEALTH DISTRICT <br /> FOR`-OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 ``// <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. T5 <br /> � <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 /> 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 /> .TOB ADDRESS/LOCATION - � .�� CENSUS TRACT 2-SS--0ir®-0/ <br /> Owner's Name C%- CAI (O• Phone <br /> -Address. 0 �� / _...._.._..--- ., Cit <br /> Contractor's Name License4,3171,)Phone <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN /_/ RECONDITION /-7 DESTRUCTION-/- <br /> 7 <br /> PUMP INSTALLATION Z' PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRT <br /> SEWAGE DISPO POOL/SEEPAGE �OT W <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 ravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor /4, 4' C 4z <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / J State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> ,DESTRUCTION 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 pert to or regulating well construction. Within FIFTEEN DAYS <br /> after comple ' n of my work a new wall, I will furnish the San Joaquin Local Health District a <br /> WELL DR RS ORT of the well an otify them before putting the w in use. The above <br /> infor tion is rue o h est my know�jpdge and belief. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SID <br /> FOR DEPARTMENT USE ONLY <br /> I <br /> APPLICATION ACCEPTED BY _ _ �_.� - DATE 11- 327 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE-AI;jFTNa INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 4/72 1M <br />