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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E rOr.:0rFICE F:" 1601 E. Hazelton Ave. , Stockton, Calif. <br /> t Telephone: (209) 466-6781 <br /> j APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7q_ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> I. (Complete In Triplicate) / X?a -0 / <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 Joaqui. <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> _ ,TOB ADDRESS/LOCATION _ 'CENSUS TRACT ' <br /> Owner's Name Phone <br /> Ina, „ <br /> 100 <br /> Address <br /> Aar, city <br /> Contractor's Name , ,„ License # 4$ Phone A1,-7476 <br /> i <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN/ / RECONDITION /_/ DESTRUCTION 1-7 <br /> PUMP INSTALLATION / / PUMP REPAIR Z/ PUMP REPLACEMENT /7 <br /> 0th'r' <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> i <br /> r <br /> k INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> ` Industrial Cable Tool' Dia. of Well Excavation <br /> K _ 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 <br /> `Other Other Information ' <br /> PUAT INSTALLATION: Contractor CXKWP` <br /> Type of Pump / ' H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP 'PAIR: State Work Done <br /> _ V <br /> DFgTRUCTION 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 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 /> i WELL DRILLERS REPORT of .the well and notify thembefore.putting the well in use. The above <br /> information 's true to the best of nowledge a4,n �e ief. <br /> y <br /> SIGNS / TITLE <br /> p ILOT-IMAX LOT-IMON UVERSE SIDE) 1 <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED -BY �' DATE 7 <br /> ADDITIONAL COMMENTS: ZZ <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY - DATE- INSPECTION BY DATE <br /> I - CALL 'FOR A GROUT INSPECTION PRIOR-TCS GROUTING -AND FINAL INSPECTION. <br /> I E H 1426 c /71,,. <br />