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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FORFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELT. CONSTRUCTION OR PUMP PERMIT Permit No. f2__ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete g�,� <br /> Application ie hereby made to the SanJo Triplicate) //Joaquin Local District for a erm <br /> and/or install the work herein described. This application is made in compliancetwithnSan uJoaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the Sa Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION % ►_ µ `�` '/ <br /> CENSUS TRACT <br /> f <br /> Owner's Name Phone <br /> Address S�'� tT�+ . Int 1r ���� City _ 17a r -�--=-- <br /> Contractor`s Name A&tom License #/ z?7, 4 hone ,/,2_ -'2G 7( <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN / RECONDITION /_7 DESTRUCTION /_7 <br /> PUMA INSTALLATION / / PUMP REPAIR 24)F/ 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 , <br /> 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 + <br /> Irrigation Gravel Pack Depth of Grout'Seal <br /> Other Rotary Type of Grout Z , <br /> Other Other Information <br /> PUMP INSTALLATION; Contractor �� <br /> Type of Pump <br /> H.P. d <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR., <br /> State Work Done <br />.RESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> ;E <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 know and belief. <br /> SIGNE <br /> TLE t--� <br /> RAW PL T PLAN ON RSE SID <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS ' III/FI AL INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTIORU <br /> E H 1426 7/72 1M <br />