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t Try"', <br /> SAN JQAQUIN LOCAL HEALTH DISTRICT <br /> i*"OF. OFFICE USE: 1.601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (.209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit Na. <br /> k <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 District. <br /> 2Zoq Mtl RI POSP <br /> JOB ADDRESS/LOCATION oO} 9 y+a CENSUS TRACT , <br /> I <br /> Owner's I ame � .fin,. <br /> �+ Phone 9138 9c <br /> Address ,S,p _ City <br /> Contractor's Name S' / -- License ��� Phone <br /> �i d' <br /> TYPE OF'JWORK (Check): NEW WELL '/% DEEPEN '/ I RECONDITION/ / DESTRUCTION /? <br /> PUi2P INSTALLATION / / PUMP REPAIR '/ / PUMP REPLACEMENT <br /> Other <br /> DISTANC-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 -1 Drilled Dia. of Well Casing i <br /> Domestic/public Driven Gauge of Casing. i <br /> Irrigation Gravel Pack Depth of Grout Seal -- -- i <br /> Other a Rotary Type of Grout <br /> r Other Other Information <br /> li <br /> r PU1�'P INSTALLATION:F <br /> l�Contractor <br /> E _ {. : Type of Pump H.P. <br /> f PUMP REPLACEMENT:; /t.� State Work Done <br /> Y"PUMP-'tEPAIR: " __ %/v 5`tate�Warlc Done W cr 1� � <br /> _ Approximate Depth <br /> DFgTRUTION OF WELL: ; Well Diameter pp P <br /> r - Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations o£ the San Joaquin Local Health District <br /> and the State of California pertaining to or regulating well "construction. Within FIFTEEN DAYS <br /> 1 I will furnish the San Joaquin Local Health District a <br /> after completion of my; work on a new well, <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 of any knowledge and belief. <br /> E <br /> i TITLE <br /> j SIGNED <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> a <br /> FOR DEPARTMENT USE ONLY d <br /> PHASE I4 j <br /> APPLICATION ACCEPTED BY ATE <br /> ' ADDITIONAL COIND ENTS: n <br /> PHASE II -:GROUT INSPECT ON P S ' YI / INSPECTION <br /> INSPECTION BY DATE INSPECTIO Y !; DATE - Z - <br /> - CAL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. 3:5/731M I <br /> F of �1.)r, It <br />