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s SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: f ' 1601 E. Hazelton"Ave. , Stockton, Calif. <br /> 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 <br /> (Complete In Triplicate) . <br /> a <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 � <br /> County Ordinance No11$62 and the Rules and°Regulations of the San Joaquin Local Health District. <br /> JOE ADDRESS/LOCATION Q dc- CENSUS TRACT <br /> Owner's Name. Q=t y! 14:4 Phone q <br /> ,Address 4,1170 <br /> .. JL City � <br /> Contractor's Name f f License #1'l hone <br /> A01? <br /> (Che <br />�'`TYPE�F�+TORKT(Check} NEW_WE=L] DE•EPEN-�/-/ -RECONDITION=/_Z-�—."DEST-RUCK-IONS_ <br /> PUMP IiSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT /_ <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK 35.0( 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 <br /> Domestic/private Drilled Dia, of Well Casing � } <br /> Domestic/public Driven Gauge of Casing 164 Q, <br /> Irri a on Gravel Pack Depth of Grout Seal (� <br /> Others - _ Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATIONt'"", .Contractor Ari all4r, 41994t •+w � . <br /> .� Type of. Pump _ H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done u <br /> DESTRUCTION-OF.�WELL =- Wel-l-Diameter - y_ _ — - -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 /> 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 /> SIGNED TITLE . <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I �n� <br /> APPLICATION ACCEPTED BY - tl�JC DATE <br /> ADDITIONAL COMMENTS: x <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. v <br /> E H 1426 4/72 1M <br />