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S <br /> 5 <br /> .w T� <br /> .W <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF..*OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION..Fbk WELL CONSTRUCTION OR PUMP PERMIT Permit No. y- .; P-1 <br /> THIS PE IT 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 Ileel.th District. <br /> JOB ADDRESS/LOCATION 160C CENSUS TRACT <br /> Phone <br /> Owner's Named _ <br /> - A <br /> Address o� 'J~d .S ar City . .. " U <br /> Contractor's Name License # J?� Phone kik- '?). P6 <br /> TYPE OF WORK (Check) : NEW{WELL -IT DEEPEN '/ / RECONDITION / / DESTRUCTION /_7 <br /> PUMP INSTALLATION j / PUMP REPAIR / / PUMP REPLACEMENT /�` <br /> Other L-1 <br /> DISTANCE Tb NEAREST: SEPTIC TkNK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial X Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing _ <br /> Domestic/public Driven Gauge of Casing /o.,cl U4 — <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information ' <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> f. <br /> w <br /> PUMP REPLACEMENT: j f State Work Done "- t <br /> PUMP '2EPAIR: / State Work Done <br /> r <br /> ,DFsTRUCTION OF WELL: Well Diamete:t Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply wJ.th 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 ! TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) - — -- <br /> R DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED .BY �' _ C�L2�L� DATE f 7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE 174/,FINAL INSPECTION <br /> INSPECTION BY DATE _ 1 INSPECTION BY DATE <br /> . CALL FOR A GROUT -INSPECTION PRION TO GROUTING AND FINAL INSPECTION. <br /> -- - - - tf 17'2- N <br />