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i <br /> SAN .TOAQtJIN LOCAL HEALTH DISTRICT <br /> Or.�OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 -57 9jG <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 Jbaqui.t <br /> County Ordinance .No. 1862 and the, Rules and egulati.ons of the San Joaquin Local Health District, <br /> JOB ADDRESSILOCATION -3. 141 - CENSUS TRACT <br /> Owner's Nave Phone <br /> Address �� a- � GQ-u.P —_ City <br /> Contractor's Name / `/� License # .2,,P6,vZ Phone "eV 3— / <br /> TYPE OF WORK (Check) : NEIN WELL -/ I DEEPEN I / RECONDITION / / DESTRUCTION /-7 <br /> PUH:F INSTALLATION /4-r PUMP REPAIR / j PUMP REPLACEMENT j? <br /> d Other I / <br /> i DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> 4 <br /> INTENDED DISE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Iiia, of Well Excavation C <br /> j Domestic/private k Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing C <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other ^ Rotary Type of Grout . <br /> Other Other Information <br /> I <br /> M PUMP INSTALLATION: Contractor <br /> j Type of Pump H.P. <br /> i <br /> PUMP REPLACEMENT., Elf State Work Done r� <br /> - <br /> �-�` <br /> DFCTRUCTION OF WELL: Well Diameter Approximate Depth <br /> R - Dedcribe Material and Procedure -- <br /> i � <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 "construetion. Within FIFTEEN DAYS <br /> i' 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 /> F information is true to h best of" my knowledge and belief. <br /> SIGNED <br /> TITLES <br /> ,i (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> .rt P14ASE I <br /> APPLICATION ACCEPTED .BY RATE _ <br /> ADDITIONAL COMMENTS: <br /> k PHASE I GROUT INSPECTION P S I /FINAL INSPECTION <br /> INSPECTION BY a DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSP ION. <br /> -7?. Tj 14'?A - 5/731M -��, <br />