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ii SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> . ' <br /> `,,, 1601 E. Hazelton Ave. , Stockton, Calif <br /> FOR OFFICE USE <br /> Telephone: (209) 466-6781 <br /> PLICATION FOR WELL ,CONSTRUCTION OR PUMP PERMIT Permit No. • <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED . _ Date Issued 7-6 - -7 <br /> (Complete In Triplicate) <br /> Applicat on.-is :hereby"made "ta ct <br /> the San Joaquin $o aapplcal icationDistmade inrict .'compliancea permit twith nSan uJoaquin i <br /> and/or install the work herein described. Th pp <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Loca1 'Health District. <br /> . � L-/V CENSUS TRACT <br /> JOB ADDRESS/LOCATION <br /> L 1#/i <br /> .. <br /> Phone ' - <br /> owner's Name : a 0 <br /> �. G �t <br /> City <br /> Address . A- <br /> License 4� bPhone 4,4 4,9 rel 9 <br /> Contractor's IName <br /> STRUCTION <br /> TYPE OF WORKI (Check) : NEW WELL/ / DEEPEN / U1�iP REPAIR PUMP PUMPEREPLACEMENT� <br /> PUMP INSTALLATION/ / <br /> �@ Other / / <br /> II ' <br /> + DISTANCE TO NEAREST: SEPTIC TANK fap/ SEWER-LINES PIT PRIVY <br /> f SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> f it <br /> INTENDED USE . PEpF WELL - CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool se Dia. of Well Excavation <br /> t Drilled Dia. of Well Casing <br /> Domestic/private T <br /> ' Domestic/public ��. <br /> Driven Gauge of Casing <br /> Irrigation Gravel Pack .Depth of Grout Seal <br /> Rotary Type of Grout <br /> Other <br /> other Other Information <br /> PUMP INSTALLATION: Contractor <br /> H.P. ` <br /> Type of Pump <br /> it <br /> PUMP REPLACEMENT: / State Work Done , <br /> State Work Done - <br /> PUMP .REPAIR: <br /> i, Approximate Depth <br /> ,R STRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure <br /> I ereby. a$ree to comply with all laws and regulations of the San Joaquin Local Health District <br /> a d the State of California pertaining to or will furnishethecSantJoaquin•L cal Health District a <br /> atfter completion of my work on a new well, <br /> k WELL DRILLERS REPORT of the well and notify..them .before putting-the well in use. The above <br /> �informatioi� is true to the best of my knowledge and belief. <br /> TLE <br /> SIGNED <br /> (D E SID <br /> W PLO LAN ON REVERS <br /> ` it FOR DEPARTMENT USE ONLY <br /> PHASE I 11. --• r DATE <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAECOMMENTS. PHASE III FINAL INSPECTION <br /> PHASF�. II GROUT INSPECTION INSPECTION BY /.7 DATE ��� -� <br /> INSPECTION BY DATE <br /> CALL;FOR A GROUT,INSPECTIDN PRIOR TO GROUTING AND FINAL INSPECTION. 4J72 1M <br /> E H 1426 <br />