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24� SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF..OFFICE US ,: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. jy-- r-lci <br /> . THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made`lto 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 Joaquit <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local: Health District, <br /> JOB ADDRESS/LOCATION4.4' CENSUS TRACT <br /> Owner's Named a d-p Phone <br /> k Address _ <br /> GP City '-, (��C.r�f'�'7�'►�.,._ <br /> Contractor's Name License # Phone 74 <br /> TYPE OF WORK (Check) : NEW.kWELL / / DEEPEN Jam/ RECONDITION/ j DESTRUCTION /? <br /> PUMP INSTALLATION / / PUMP REPAIR PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> 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 <br /> +r .._ Domestic/public Driven Gauge of Casing 6 <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> _ ..r-TYPe_of Pump i - H.P. � . . <br /> PUMP REPLACEMENT: / / � State Work Done <br /> PUMP+'tEPAIR: State Work Doge ? p <br /> 41. <br /> r <br /> ,DRCTR'JCTION OF, WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulationsofthe San Joaquin Local Health District <br /> and 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 .the well and notify them before putting the well in use.- The above <br /> f information is true to the 'ibest of my knowledg n elief. <br /> c <br /> SIGNED i 1. TLE :�-=-.�' <br /> D PLOT ON R RSE SIDE)k-lor-_ IF - _ <br /> '? FOR DEPARTMENT USE ONLY <br /> PHASE I , <br /> APPLICATION ACCEPTED .BY Cie DATE <br /> ADDITIONAL COMMENTS: _ <br /> PHASE II GROUT INSPECTION PHAS I I/FINAL INSPECTI N <br /> INSPECTION BY. DATE INSPECTION .BY DATE ;l 2 -3 <br /> CALL-FOR A GROUT1NSPECTION PRIOR TO GROUTING .AND FINAL INSPECTI <br /> E H 1426 5/731M <br />