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SAN JOAQUIN LOCAL, HEALTH DISTRICT ltlz0 <br /> FOR OFFICE USE: 1601 E. Haxelton 'Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. `�_91 W <br /> THIS PERMIT 'EXPIRES 1 YEAR .FROM..DATE ISSUED Date Issued - <br /> .(Complete In Triplicate) <br /> Application is hereby made 'torthe San 3oa4uin Local Health ,Districtjor a ',permit -to construct <br /> and/or install the work. herein described. This application is .made in compliance with' San Joaquin <br /> County Ordinance No. 186 andthe Rules and Regulation o£ the San Joaquin Local Health District. <br /> too <br /> lJinr <br /> JOB ADDRESS/LOCATION CENSUS +TRACT ' <br /> Ownerrs Name , s %� /�� Phone . <br /> Address SX.r —�. --- -- ..w ::...._ City <br /> Contrac.to,r�!.s„Name. cense hone <br /> TYPE OF WORK (Check) : ,, NEW WELL DEEPEN /_� RECONDITION J� DESTRUCTION /� <br /> PUMP INST LATION / / PUMP REPAIR / / PUMP REPLACEMENT /� <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISP S FIE D CESSPOOL EPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation <br /> ` Domestic/private Drilled Dia. of Well Casing 119IV <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 /> y <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work-Done <br /> PUMP REPAIR: / / State Work Done <br />' ,DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and. Procedure <br /> I hereby agree to comply with`al.l 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 them before putting the well in use. The above <br /> t information true to the of m knowledge and belief. - <br /> SIGNED TITLE <br /> (DRA LOT PLAN ON REVERSE SIDE <br /> F R DEPARTMENT USE ONLY <br /> PHASE I VIAZp <br />;' APPLICATION ACCEPTED BY DATE 4 X <br /> ADDITIONAL COMMENTS: <br /> PHASE jj GROUT INSPECTION PHASE 41JJFINAL INSPECTION <br /> INSPECTION BY _ DATE 0= 2„ '— INSPECTION BY DATE <br /> CALL .FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 14267/72 1M <br />