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SAN JOAQUfN LOCAL HEALTH DISTRICT <br /> f 0 ,:OI'k I(E US1:• 1601 E. Hazelton Ave-3 Stockton, Calif. <br /> ------- Telephone: (209) 466-6782 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> 7 J 3y7� <br /> "w Date Issued <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED j sd�0 <br /> ct <br /> C- <br /> (Complete In Triplicate) a ©S4` <br /> Application i's hereby made to the San Joaquin Locallicati.on Health istmade inrict rcompliance ermit twith nSan uJoaquin <br /> and/or in thelwork herein described. - This app <br /> and/or <br /> Ordinance No. 18b2 and the Rules and Regulations of the San Joaquin Local Health Dist is t <br /> County . <br /> �UENSUS TRACT <br /> JOB ADDRESS/LOCATION <br /> e Phone <br /> Owner's Name r <br /> f City <br /> Address <br /> License 1 �'Phone �� � <br /> Contractor's Name Da-e,- ,�7,�, --•l <br /> PE OF WORK (Check) - NEW WELLil DEEPEN / / RECONDITION / / DEREPLACEMENT /� <br /> PUMP INSTALLATION / PUMP REPAIR / / PUMP -- <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> PIT PRIVY _ <br /> i SEWAGE DISPOSAL FIELD - CESSPOOL/SEEPAGE PITT - OTHER <br /> TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> INTENDED USE Cable Tool Dia. of Well Excavation <br /> Industrial. -- Dia. of Well Casing <br /> Domestic/private Drilled _ <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation � Gravel Pack Depth of Grout Seal - C4 <br /> __�'S,_ Rotary Type of Grout <br /> Other- Other Information <br /> Other <br /> E <br /> k PUMP INSTALLATION: Contractor f. e H.P. 0_ / <br /> Type of Pump <br /> Ir PUMP REPLACEMENT: /- / State Work Done . <br /> RR P"'"t3MP`t PAIR. to Work~Done <br /> Approximate Depth <br /> 4 DF1TRUCTION OF WELL:- '"Well Diameter <br /> y. Describe Material and Procedure <br /> I hereb agree to comply with" all laws and regulations of the San Joaquin Local Health District <br /> j Y <br /> F and the State of California pertaining to or regulating well''construction. Within FIFTEEN DAY <br /> after completion of my work an a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS RE of the well and Notify, them before putting the well in use. The above <br /> infor-matio i true to if Eny. nowledge.- and belief. <br /> _ TIT_� <br /> SIGNS S DI E <br /> <.. (DRAW PLOT PLAN ON REVERSE ) <br /> r FOR DEPARTMENT USE ONLY <br /> t PHASE I DATE <br /> APP ICATION ACCEPTED BY, <br /> ADDITIONAL COMMENTS: p III/FINAL INSPECTION <br /> PIiA IT GROi3T INS CT INSPECTION BY DATE <br /> INSPECTION BY DA E • <br /> CALL FOR A-GROUT.-INSPECTION-PRIOR TO..GROUTING AND FINAL .INSPECTION. 5�?3 <br /> . ._ <br /> rs IT 1 - - -_ <br />