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.: ' ., V� y�.s' • _ �. ..�.._ SII <br /> SAN JOAQUIN LOCAL REALTH DISTRICT <br /> FOT. pFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (204) 466-6781 3 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �y- <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 , <br /> County Ordinance: No. 1862 and the Rules and Regulations of the San Joaquin Local Health Dis4rict. <br /> .TOB ADDRESS/LOCATION' . � loc . .., CENSUS TRACT � <br /> Owner's Name Phone — V 74 7 <br /> Address City <br /> a' <br /> Contractor's Name ..•,"� -- s ' , i icense � //(O.AQaVhon- <br /> i <br /> TYPE OF WORK (Check): NEW WELL 1_90 DEEPEN %/ RECONDITION / / DESTRUCTION /7 s <br /> PUMP INSTALLATION / f PL`MP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other /_7 — <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> 1/ 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 •� j <br /> Domestic/public, Driven Gauge of Casing - 1 <br /> Irrigation ., Gravel. Pack Depth of Grout Seal <br /> Other Rotary Type of Grout 6Ir7 L ✓ -- <br /> R <br /> Other Other Information *"W C. <br /> 1 1 <br /> i <br /> PUP'IP TNSTALT;ATION: Contractor <br /> Type of Pump- H.P. <br /> r <br /> PUMP REPLACEMENT: /7 State Work Done <br /> PUMP 'tEPAIR: / / State Work Done <br /> ,DFGTRUCTION OF WELL: Well Diameter, Approximate Depth <br /> E Describe Material and Procedure <br /> f <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 'construcfion. 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 fof my knowledge and belief. <br /> SIGNED ;r.& :,m, • .. 60. TITLE <br /> L ON REVERSE SIDE) <br /> R DEPARTMENT USE ONLY . <br /> PRASE I <br /> APPLICATION ACCEPTEDBY ��_`'�-/ DATE <br /> ADDITIONAL COMMENTS: <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. <br /> E H 1426 5/731M <br />