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SAN JOAIQUIN LOCAL HEALTH DISTRII�T <br /> Enclz USE, 1601. E. Hazelton Ave., Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ,a_ <br /> THIS PERMIT EXPIRES 1 UAR FROM DATE ISSUED Date Issued <br /> i, j -70 <br /> (Complete In 2-55 <br /> Application is hereby im "e - o the San Joaquin Local Realth District for a permit to construct <br /> and/or install the work herein described. * This application is made in compliance with Ban Jpaquil <br /> County Ordinance No. 1862 and the Rules aad Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> WAZZ kda._tw 4zi4 i <br /> Owner's Name Phone <br /> Address city <br /> Contractor's Name 4 41 AZ License # Phone S <br /> TYPE OF WORK (Check): NEW WELL DEEPEN RECONDITION DESTRUCTION r7 10 <br /> PUJ T INSTALLATION �l PLW REPAIR PUMP REPLACEMENT I-T 9 <br /> Other 1_7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWE;A LIKES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SE9PAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> industrial Cable T*ol 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 , Jt <br /> Other Other Informatton <br /> PUMP INSTALLATION: Contractor .4plin, <br /> Type of Pump <br /> .d U& <br /> A-P. <br /> V <br /> PUMP REPLAGED%NT State Work Done <br /> PUMP 'OEPAIR: State Work Done <br /> ,I)FAIRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regkilatlons 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 DRILLERS REPORT of the well and notify them before putting the veil in use. The above <br /> information is true to the best of my kuovledge and belief. <br /> SIGNED _ TITLE <br /> DRAW <br /> DRAW4,&Al PLWM' PLAN ON REVERSE- SIDE V <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY Ldo DATE <br /> ADDITIONAL =MMENTS. YNS�EGTION <br /> 1411FINAL <br /> Pffi�SE II GROUT INSP CTION PHASE ZI/ <br /> INSPECTION By DATE INSPECTION BY L-kP- DATE 7277,L22 <br /> CALL FOR A GROUT INSPECTION FRI-OR TO GROUTING AND FINAL INS ON. <br /> T7 TY 1 1.9< <br />