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a <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 f.. Itaaelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781. <br /> APPLICATIO:3 FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> ;. <br /> 7YETMS FI;RNIT EXPIRES 1 Y AR FROM DATE ISSUED Date Issued <br /> (Complete la Triplicate) <br /> Application is hereby made to the San Joaquin Local 11ealth District for a permit to construct <br /> and/or install the work herein described. This a,:plication is made in compliance with San Joaquin; { <br /> County Ordinance No. 1862 and Ch ules and Reg-_jlat•t.)cis of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 4 � !`��-�v -� CENSUS TRACT <br /> 4 7.e--i[.-a/..-.-.....� <br /> Owner's Name ' ^ <_ Phone <br /> F, f <br /> ? City <br /> Address � 0" I d-ti-� C,, •-�/ , - ? <br /> Contractor's Name License Phone3G,� <br /> 1i <br /> TYPE OF WORK (Check):. NEW WELL DEEPEN_/ / RECONDITION /-7 DESTRUCTION /-7 <br /> PUMP INSTLATION .1 / PUMP REPAIR Q5r' PUMP REPLACEMENT /� <br /> AL <br /> Other <br /> , <br /> • DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER �; t <br /> k F� <br /> {f!{ INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS vim' <br /> Industrial Cable Tool Dia, of Well Excavation l <br /> - � Domestic/private Drilled Dia. of Well Casing <br /> #? Domestic/public _ Driven Gauge of Casing <br /> Irrigation Gravel Pack Deptii of Grout Seal <br /> ' t Other Rotary Type of Grout <br /> Other Other Information <br /> ;i PUMP INSTALLATION: Contractor <br /> L _ � <br /> Type of Pump ---. 1' - H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: State Work Done <br /> ,)ESTRUCTION OF-WELL: Well Diameter _ Approximate Depth <br /> } Der;cribe Material and Procedure <br /> f I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District - r <br /> and the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> i after completion of my work on a new well., I will furnish the San Joaquin Local Health District a <br /> j WELL DRILLERS REPORT of the well and notify them before putting the well. in use. The above <br /> i inforoation is true to the beat of my knowledge and belief. <br /> SIGNED _ � � "� _ TITLE <br /> RAW PLOT PLAN_ON REVERSE SIDE _ <br /> FOR DEPARTMENT USE ONLY ti <br /> I <br /> PHASE I <br /> i APPLICATION AC:.EPTLD BY"n&� DATE <br /> ADDITIONAL COMMENTS: _ <br /> 3 PRASE TI GROUT tNSP1CT1ON PHASE III/FINAL INSPECTION <br /> INSPECTIOid BY� DATE INSPECTION BY _�� DAT— EE ! : <br /> ( CALL FOR A GROUT INSPECTION PRIOK TO -ROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br /> i <br /> r. <br /> Y <br /> 1, <br />