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I <br /> SAN JOAQUIN LOCAL HEALTH DI T �WeV� <br /> i OI. Of FIC;L USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (.209) 466-6781 <br /> APPLICATION FOR WEU CONSTRUCTION OR PUMP PERMIT Permit No. 7_69,34d <br /> 77-6ss� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete, In Triplicate) <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 Joaquin k <br /> County Ordinance N 1.862 and the Rules and Regulations.. of the San Joaquin Local Health District, <br /> JOB ADDRESS%LOCATION ENSUS TRACT ' <br /> Name Phone <br /> Address City <br /> 5 <br /> License 4honeContractor s Dame Cc=i1171.x613 <br /> {{ <br /> TYPE OF WORK (Check) : NEW- 14ELL DEEPEN f/ RECONDITION /�.{ DESTRUCTION /_7 <br /> PUMP INSTALLATION PUMP REPAIR / I PUMP REPLACEMENT /� <br /> � <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TA''�K SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation \S} <br /> Domestic/private Drilled Dia. of Well Casing z ' <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Sea] 4d � i <br /> Other - Rotary Type of Grout <br /> Other Other Information <br /> 47I <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump, H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP 'ZEPAIR: / / State Work Done <br /> DF9TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure - --- <br /> I - <br /> f I hereby agree to comply with all laws ancV 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 /> 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 /> i SIGNED - r.Y ,�Y1a/.l�.Cr - - TITLEfYlpJ1 <br /> 3 <br /> . .(DRAW PLOT PLAN ON REVERSE SIDE) <br /> F DEPART NT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED .BY DATE <br /> ADDITIONAL COI�NTS: <br /> PHASE iI GROUT INSPECTION PRASE III/FINAL INSPECTION <br /> INSPECTION BY DATE a- INSPECTION BY DATE f2l-61) F <br /> CALL TOR A•GROUT INSPECTION-PRIOR-TO.GROUTING.AND .FINAL INSPECTION. <br /> __ I 'll c;/71im <br />