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t <br /> JOAQUIN LOCAL HEALTH DISTRICT—) <br /> FOR OFFICE USE: 160-L ,-E. Hazelton Ave.'; Stockton, Cal__-: <br /> Telephone: , (209) 466-' 6781 ' <br /> APPLICATION FOR WELL CONSTRUCTION '.OR: PUMP PERMIT Permit No. . 2-41 0 <br /> THIS PERMIT. EXPIRES 1 YEAR'•FRO.M DATE ISSUED- Date Issued 7- 11" 77i <br /> ("Complete In-,Tiriplica.te) <br /> Application is hereby-madedto .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.X1862':-and% the:Rules:`and,kegulations of the San Joaquin "Local Health District: <br /> JOB ADDRESS/LOCATION �� 3'3.- ML <br /> A-✓� CENSUS TRACT ' <br /> Owner'.s Name -~ V,4— CFrI -- Phone <br /> Address _ � _�L .rrlfoCit. y 7`�✓`�`a� <br /> -, .. (� <br /> l Contractor's Name License # Phone t y �Zf74 <br /> TYPE OF WORK (Check) : . NEW WELL "/7 DEEPEN "/-7. RECONDITION /_7 DESTRUCTION /-T <br /> PUMP INSTALLATION-% %_ PUiT-REPAIR REPLACEMENT /_7 <br /> Other / / <br /> — i <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 r/ <br />[ Industrial I Cable Tool Dia, of Well Excavation <br /> Domestic/private E Drilled Dia, of,Well Casing, A <br /> - - V <br /> Domestic/public 3 Driven "x�" Gauge' of Casing <br /> Irrigation Gravel .Pack-" Depth of Grout Seal <br /> Other 1 Rotary Type of Grout <br /> Other Other- Information <br /> PUMP INSTALLATION: Contractor <br /> Type .of Pump H.P. 3 <br /> PUMP REPLACEMENT: / / State Work Done, <br /> PUMP REPAIR: State Work Donel /,� �/S / � .,L J'd .�m✓/�ee.�i o+� <br /> DESTRUCTION OF WELL: Well Diameter 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 /> i 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 off my knowled d belief. <br /> SIGNED <br /> PL-VTLAN ON R-EVARSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I n <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PMS-4PMS-4 II GROUT INSPECTION PHASE III/FINAL INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY DATE J <br /> CALL FOR Ar GROUT .INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. �l%N <br /> E H 1426 4/72 1M <br />