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' SAN JOA UIN LOCAL HEALTH DISTRICT <br /> FOR.'OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION .OR PUMP PERMIT Permit <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE° ISSUED Date Issued_�Q <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 District. <br /> JOB ADDRESS/LOCATION ,20C CENSUS..tRACT - <br /> Owner's Name _F= <br /> C~ _ Phone <br /> t Address _ 2,0 6!Z& S_ N LS City_. <br /> Contractor_'.s .Name _ FO_K _A+4 _�I-E-TRK icense44� <br /> _. WJ1 = <br /> �-- - <br /> TYPE OF WORK (Check): NEW WELL /_7 DEEPEN _/ RECONDITION /- DESTRUCTION /_7 <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT 1_7AL <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK r-SEWER'DINES `--PIT-..PRIVY------ <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> TENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool ';Bio of WeIT Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing C11 <br /> Irrigation . __ Gravel Pack __,,-_Depth of_Grout_ Seal_ <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Gent ..e fie.._ CT ( , <br /> f Type of Pump H.P. <br /> PUMP REPLACEMENT: L/ State Work Done <br /> PUMP REPAIR°� �� <br /> State Work Done <br /> Approximate ESTRUCTIQN OF WELL: Well Diameter A Pp Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> an&the State ,of California pertaining to or regulating well construction. 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 th well and notify them before putting the well in use. The above <br /> E in£ormati is true o th bestof y knowledge and belief. <br /> SIGNED c TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE)-- <br /> --------.FOR <br /> IDE <br /> . �..�...._T,..._..... ._FOR-DEPARTMENT-TISE <br /> PHASE I <br /> APPLICATION ACCEPTED BY = DATE ....��5-Z - <br /> ADDITIONAL­­­__ TS: ~_F r <br /> PHASE II GROUT INSPECTION PHAS I°I ,�LNAL INSPECTIONQ <br /> INSPECTION BY DATE '0 Y- DATE <br /> H <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H' 1426 7/72. 1M CZ <br />