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C,%1` SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF..O1'FICE USE: <br /> 1601 E. Hazelton Ave. , Stockton, Calif. <br /> I Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date issued 7th <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> and/ox instar. the work herein described. ' This application is made in compliance,with San Joaquin, <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local health Disrrict. - <br /> CENSUS TRACT <br /> t;B10`=DRiS//?0&ON IY �`I. �• <br /> Phone <br /> Owner's Name II <br /> City 17.1 i/%S , <br /> I Address y` 0 x G� <br /> `. .� �7 <br /> -_�;. Licerise��� �4G(/%Z Phone . <br /> Contractor's Name - <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN Imo/ RECONDITION / / DE PL�►cl - -7 <br /> PUMP INSTALLATION / P�,MP REPAIR 1 / PUMP <br /> Other l / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE PTYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Dias, of.,Well Excavation <br /> Cable Tool; <br /> Industrial; <br /> Domestic/private Drilled -� �~ Dia:of Well Casing <br /> Domestic/public <br /> Driven Gauge of Casing ` G <br /> Irrigation ' Gravel Pack Depth_of Grout Seal �. <br /> Other Rotary_ Type of Grout F=� <br /> Other ` Other Information ' i <br /> PU1-T INSTALLATION' Contractor <br /> "--"- '�Lype of'-Pump H.P. ' <br /> PUMP REPLACEMENT: / / State Work Done` <br /> ,..- <br /> PUMP '7EPAIR: / State Work Done <br /> DF 'TRUCTION OF WELL: Well Diameter Approximate Depth <br /> # Describe Material and Procedure <br /> S <br /> I hereby agree to comply with all Laws and regulations of the San Joaquin; WithinaFIFTEENtDAYS <br /> and the State of California pertaining to or regulating well ''construction' <br /> I will furnish the San Joaquin Local Health District 4 <br /> after completion of my work on a new well, <br /> WELL DRILLERS REPORT of .the well and notify them before putting the well in use. The above <br /> ' information is_true,to- the best of my knowledge and belief. <br /> TITLE --- <br /> SIGNED i. , <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> 4 FOR DEPARTMENT USE ONLY <br /> E PHASE I <br /> _ DATE Lo iS7y <br /> t APPLICATION ACCEPTED .BY-iU-r-p- , - <br /> ' ADDITIONAL COMMENTS: ' <br /> PRASE II GROUT INSPECTION PHASE.III/FINAL INSPECTION r� <br /> t: DATE �S�' '►° ,' INSPECTION BY ./_ '. DATE // — 9 '. ` <br /> INSPECTION BY �. — = Of ` <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND-FINAL INSPECTION. <br /> :. __ 5/731X_ <br />