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y I"�'FL'6CAL HEALTH DISTRICT <br /> SAN JOAQUI <br /> tockton, Calif. <br /> �'OF.:OIy`F�'ISE USL: lbbl E. Hazelton Ave. ,Ave. <br /> Telephone: (209) 466-6781 Permit No. �-?' a� <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> � FROM Date Issued <br /> THIS PERMIT EXPIRES !BAR pli c e)DATR ISSt3ED <br /> (completepermit to construct <br /> cal Health <br /> IM Application is hereby made to the cribedan a4uin This apglieat3on District <br /> tmade in cin Local Heal.thSan <br /> District' <br /> i and/or install the work herein des <br /> County Ordinance Nov 1862 acid the Rules and Regulatone of the San Joaquin <br /> �0 1' CENSUS TRACT <br /> JOB ADDRESS/LOCAQN . Phone <br /> Owner's Name d I <br /> City . . <br /> Address <br /> c License Ja+)079 Phone a b �b <br /> Y <br /> Contractor's Name a rni-i J �N <br /> E � DEEPEN '//�/ RECONDITION_/ <br /> DESTRUCTION IJT <br /> TYPE OF WORK (Check) . NEW WELL pL+l„� REPAIR' / PUMP REPLACEMENT /� <br /> t PUMP INSTALLATION <br /> Other <br /> I SEWER LINES PIT PRIVY <br /> DISTANCE TO NEAREST: SEPTIC TANK CESSPOOL/SEEPAGE PIT OTHER <br /> SEWAGE DISPOSAL FIELD <br /> TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> INTENDED USE Dia. of Well Excavation <br /> Industrial <br /> Cable Tool <br /> f Drilled Dia. of Well Casing <br /> Domestic/private Driven Gauge of Casing <br /> Domestic/public . Depth of Grout 'Seal <br /> Irrigation D I <br /> Gravel Pack P R <br /> ' -- —�r Rotary Type of Grout <br /> Other Other Information <br /> �—--- Other r <br /> C <br /> i <br /> PUMP INSTALLATION: Contractor H.P. <br /> i Type of Pump <br /> PUMP REPLACEMENT: / / State Work-Done <br /> PUMpw'tEPAIR:. / State Work Done <br /> t DF-TRUCTION OF WELL: Well Diameter <br /> Approximate Depth _ <br /> Dascri.be 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 <br /> WELL DRILLERS REPORT of the well and notify them before putting the well in use. <br /> The above <br /> informat' is true o t e be of my knowledge and belief. <br /> TITLE -- <br /> SIGNED (D QT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE. ONLY t <br /> 1, <br /> PHASE I DATE <br /> APPLICATION ACCEPTED .BY ; <br /> ADDITIONAL COMMENTS: = PHASE III/FINAL INSPECTION <br /> t PHAS II.-GROUT INSPECTION <br /> INSPECTION BY DATE _ <br /> INSPECTION BY <br /> ¢ CALL FOR A GROUT INSPECTION PRIOR -TO-GROUTING AND FINAL INSPECTION. 5/731M <br />