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SAN 4,,,..QUIN LOCAL HEALTH DISTRICT %E/ <br /> TF-OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 3-3o y <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 6-t <br /> (Complete(Complete In Triplicate) <br /> 1 ration is hereby made to the San Joaquin Local Health District for a permit to construct <br /> /Sr install the work herein described. This application is made in compliance with San Joaquin. <br /> ntv Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> tiDRESS/LOCATION �fI�_. ZY/ all CENSUS TRACT <br /> ei s Name Phone <br /> cess 296 f City. ���� <br /> ct�ctor's Name i 6P��5�8 <br /> Licensq_?#E J"v ,Phone <br /> F WORK (Check) : NEW WELL /-7 DEEPEN /% RECONDITION /-7 DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR X1 PUMP REPLACEMENT /-7 <br /> Other / / — <br /> 'A_E TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> -'*ndustrial Cable Tool Dia. of Well Excavation <br /> - Domestic/private Drilled Dia, of Well Casing <br /> iomestic/public Driven Gauge of Casing <br /> -irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> - Other Other Information <br /> I"STALLATION• Contractor <br /> Type of Pump <br /> REPLACEMENT: / / State Work Done <br /> R►2AIR d' State Work Done ��_ � <br /> U CION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Trocedure <br /> 0- agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> hi State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> Mmpletion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> m. ionis true <br /> /to�the best of my knowledge and belief. <br /> D <br /> TITLE > <br /> (DRAW PLOT PLAN ON REVERSE SID <br /> FOR DEPARTMENT USE ONLY <br /> I <br /> fE ION ACCEPTED BY <br /> tC_AL COMMENTS: DATE <br /> - <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> :TION BY DATE INSPECTION BY <br /> DAT& <br /> ,I FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> [ 1426 <br /> 7/7? to <br />