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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> I: <br /> FOR OFFICE USE: 1601 E. Hazelton'Ave ,' Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR'WELL ,CONSTRUCTION AOR PUMP PERMIT Permit No. 7.,2_4) <br /> THIS -PERMIT EXPIRES 1 YEAR FROM 'DATETISSUED Date .Issued <br /> (Coinplete_ In Triplicate) <br /> Application.is hereby imade"to,,the' San Joaquin Local 'Health District fora permit to construct <br /> and/or install the work herein described, This application is, made"'in coznpli:ance with San Joaquins <br /> County Ordinance No. 1862 and-wthe Rules and Regulations of the San'Joaquin Local 'Health District. <br /> 30B ADDRESS/LOCATION CENSUS TRACT <br /> 2GOC'( � {�CI�'7G` x w 'Phone <br /> Ownerrs Nam fA <br /> Address City: _ <br /> Contractors Name; <br /> License "Phone ( :dO <br /> 1 ti <br /> TYPE OF.-WORK {Check) :. NEW WELT, / /.._.,DEEPEN /�..�-RECONDITIONS/_ .DESTRU-CTION�./?�- �.;...�. � <br /> PUMP INSTALLATION /�/ PUMP REPAIR / PUMP REPLACEMENT /- <br /> D <br /> Other /�/ <br /> DISTANCE TO NEAREST: SEPTIC T SEWER LINES PIT PRIVY <br /> SEWAGE DISP L FIELD C SPOOL/SEEPAGE PIT OTHER (� <br /> INTENDED USE TYPE OF MEL CONSTRUCTION SPECIFICATIONS ?� <br /> Industrial, t Jam- Cable To Dia. +of Well Excavation Q <br /> Domestic/private Drilled Dia. 'of Well Casing 1 S <br /> Domestic/public Driven Gauge. of Casing / �o <br /> 1 = Irrigation Gravel ack Depth of Grout Seal <br /> Other Rota a of Grout <br /> Ot r Othe ' Information <br /> PUMP INSTALLATION: Contract r A� <br /> Type ..o Pump H.P. V" <br /> PUMP REPLACEMENT: / / State Work Don \ V �fttt :�3e <br /> PUMP REPAIR: / / State Work Done <br /> Y0 - r <br /> ESTRUCTION-UF�WELL_:' _Well Diameter Approximate-Depth--- <br /> D"e'bcribe Material and P Material <br /> I hereby, zrgree' to comply with all laws and regulations of the San Joaquin Local Health'District <br /> and"ttie- State "of California pertaining to or regulating.weli 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 /> i information is true to the best of my knowledge and belief. <br /> SIGNED - TITLE <br /> F (DRAW PLOT PLAN ON REVERSE SIDE <br /> E FOR DEPARTMENT' "USE ONLY <br /> PHASE I. <br /> .APPLICATION ACCEPTED BY ' ' DATE, <br /> ADDITIONAL COMMENTS:£' +, r <br /> r 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, <br /> 7/72 1M <br /> ' E H 1426 <br />