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f <br /> .f.iii wr 'l.. .._...s 1' ..1.•„.:3.C.1.N1: - '.N. <br /> zAN JOAQUIN1LOCAL HEALTH DISTRICT <br /> FOR 0 FICE USE: / 16DI E. Hazelton Ave. , Stockton, Calif. <br /> - Telephone: (209) 466-6781 � n <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT P No <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED Date Issued .4Z=4j=Zz- <br /> (Complete In Triplicate) <br /> i 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 /> CnuctCy Ordinance No. 1$62 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION $ CENSUS TRACT <br /> Owner's Name <br /> Phone Er-133 <br /> Address <br /> City <br /> Contractor's Name <br /> o License # Phone <br /> TYPE OF WORK (Check): NEW WELL DEEPEN /_7 <br /> RECONDITION /7 DESTRUCTION /77 <br /> PUME'r INSTALLATION /W] . PUMP REPAIR / / PUMP REPLACEMENT /2;r-- <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _ PIT PRIVY <br /> SEWAGEIDISPOSAL FIELD _CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial ,� 6 Cable Tool �, Dia, of Well Excavation - <br /> Domestic/private' Drilled "" "' Dia, of Well Casing <br /> Domestic/public ; {. Driven.J.• Gauge of Casing <br /> P <br /> Irrigation Gravel Pack Depth of Grout Seal .. <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> yType of Pump H.P. r <br /> S PUMP REPLACEMENT: /27" State Work Done �ric� �' �S f <br /> 1I PUMP REPAIR: _ µ.fl .State WorkDone <br /> ,RESTRUCTION OF WELL: Well Diameter �- ' <br /> • ... Approximate Depth <br /> Describe Material and Procedure ------ <br /> I hereby agree to comply with all laws and regulations of the Sari 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 /> information is tru to the bes of my knowledge and belief. <br />{ SIGNED TITLE <br /> DRAW PIAT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> CPHASE I �c_►-n _ • , <br /> APPLICATION ACCEPTED BY L,l: DATE <br /> ADDITIONAL COMMENTS:. 7 <br /> PHASE II OUT INSPECTION P <br /> _HAjj!nE INSPECTION <br />[ INSPECTION BY DATE INSPECTI <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 <br /> 7/72 1M <br />` ,r .n.w mq.•Snw.�.tr,:• .a-i nw ri s+.ti,,r -+.nnw,r..Fa�+�'!14..+K. i. jy..•^,a*r• .v.�ys.'Wa!fifih,..,ww.,w....,. .� . .. •� - -. .,;;;'� <br />