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r ' <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazeltoft -Ave. , Stockton, Calif. <br /> Telephone : ' (209) 466--6781 <br /> - � PLICATION FOR..WELL CONSTRUCTION OR PUMP PERMIT Permit No. -L-�0 S' <br /> 20 �{ 3 I <br /> THIS -PERMIT`EXPIRES I YEAR FROM DATE ISSUED Date Issued_'L.1-, 7 L <br /> � ��C (Complete In Triplicate) <br /> PA C made 'to the SanFJoaquin Local- Health District for a_permit .to construct <br /> rk herein described. This application is trade in compliance with San Joaqui <br /> L862--and thti-Rule' s aiid :Regulations of the San Joaquin, Local Health District. <br /> CENSUS .'TRACT: <br /> Owner's Name. r` w -' , ;ti ca c . . .3� . <br /> Phone <br /> Address L' 11L' JI y.,, J2d, City • �E` <br /> - <br /> Contractor's Nameo License #11 <br /> 37. Phone L 94 25 <br /> TYPE OF WORK (Check) c JNEW WELL DEEPEN /_ RECONDITION /� DESTRUCTION / 7 _ <br /> PUMP INST TION J / PUMP REPAIR /R/_PUMP REPLACEMENT /7 <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 /> Domestic/public Driven Gauge of Casing O <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> } Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type Iof Pump H.P. <br /> K. <br /> PUMP REPLACEMENT: _ <br /> / / State Work Done <br /> PUMP REPAIR: <br /> J / State Work Done pZ, � <br /> ,DESTRUCTION OF WELL: Well DiameterT. Approximate 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 /> 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 /> information is true to the best of my knowledge and belief. <br /> SIGNED L' ,"� a TITLE <br /> DRAW PLOT PL ON REVERSE SID <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY _ DATE INSPECTION BY Z DATE s <br /> CALL FOR A GROUT INSPECTION_PRIOR TO GROUTING-AND FINAL INSPECTION: <br /> E H 1426 7172 1M <br /> = r <br />