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SAN JOAQUIN LOCAL HEALTH DISTRICT } <br /> FOF.:OFFiCL USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.T. __5 y a) <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued /p-.2-73 <br /> . - (Complete In Triplicate) <br /> Application is hereby made tci the San Joaquin <br /> }�isoaallicati nalth gistmade inrict rcompliance twith nSan uJoaquin <br /> and/or install the work herein describe pp <br /> the Rules and Regulations of the San Joaquin Local Health District <br /> County Ordinance No. 1.862 and . <br /> CENSUS TRACT <br /> .FOB ADDRESS/LOCATION _ <br /> r Phone ' <br /> Owner's Name <br /> City S � . <br /> Address' 2' S: <br /> License # f G� Phone �1� . <br /> Contractor's Name, r N <br /> ;a <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN '/ / RECONDITION DESTRUCTION <br /> REPLACEMENT�/-T <br /> pUMP INSTALLATION / / pbW REPAIR <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES � PIT PRIVY , <br /> .SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> TYPE OF WELL <br /> INTENDED USE CONSTRUCTION SPECIFICATIONS <br /> E Cable Tool Dia. of Well Excavation <br /> Industrial — - Drilled Dia.: of-Well Casing � <br /> k ;' Domestic/private <br /> Domestic/public. <br /> Driven Gauge of Casing <br /> Gravel Pack Depth of Grout Seal <br /> Irrigation �) <br /> -- - Rotary Type of Grout <br /> Other <br /> Other _ Other Information Z, <br /> _ 1 <br /> PUMP INSTALLATION: "; Contractor H.P. <br /> t <br /> Type. of Pump <br /> PUMP REPLACEMENT: / /} State Work bone <br /> PUMP, 'tEPAIR: { / f State Work Done <br /> ` Approximate Depth <br /> DF•fiTRUCTION OF WELL: Well Diameter <br /> Describe, Material .and Procedure , <br /> cal <br /> lth <br /> rict <br /> I hereby agree to comply with all law s and relns owelle'constructson.San JoaquinL6Within aFIFTEEN tDAYS <br /> �. and the Stat& of Califoruia 'pertaining to or-regulating <br /> •a .new well, I will furnish the San Joaquin Local Health District a <br /> tWELL DRILLERS REPORT of .tt.e well and notify them before putting the well in use. The above <br /> after completion of my work on <br /> y :information is true to the best of my knowledge and-belief. <br /> J .� TITLE 62Ad4�� <br /> . <br /> SIGNED- C .� <br /> (D PLOT PLAN ON REVERSE SIDE) <br /> _. ._ FOR DEPARTMENT USE-ONLY ' <br /> PHASE I i - DATE <br /> APPLICATION ACCEPTED .BY +4 - <br /> ' ADDITIONAL,. COMMENTS: I � <br /> P SE II ROUT INSPECTION PHASE I /FIN INSPECTION <br /> iINSPECTION -BY DATE - <br /> INSPECTION BY . fAE _yti-ti� .- <br /> CALL FOR A-GR INSPECT -PRIORTO GROUTING AND FINAL INSPECTION. <br /> — . I of _.- - - <br />