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.. SAN JOAQUIN _�OCAI- HEALTH DISTRICT s <br /> FOR OFFICE.-USE: 1601 E. Haiditon Ave. , Stockton, Calif. <br /> f. Telephone: (209 466-6781 <br /> PLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Appli ation is hereby made to the San Joaquin Local Health District for a permit to construct t <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 Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> t <br /> Owner's Name Phone Wz" <br /> Address l City <br /> I <br /> Contractorts Name I U'` r �a '� License # Phone <br /> /7' z�q <br /> TYPE OF WORK (Check) : NEW'W �DEEPENS/_� RECONDIT..ION /7 DESTRUCTDIW /11 � � <br />` PUMP INSTALLATION / / PUMP'REPAIF� / s/ PUMP REPLACEMENT /� w <br /> Other ,/ / <br /> DISTANCE TO NEAREST: SEPTICATANK SEWER LINES PIT PRIVY <br /> SEWAGE. DISPOSAL FIELD CESSPOOL/SEEPAGE PIT° OTHER 1 <br /> INTENDED USE TYPE'a'OF WELL CONSTRUCTION SPECIFICATION $ <br /> E Industrial 1 Cable Tool Dia, of Well Excavation <br />" C7'-Dowestic/private ! Drilled Dia. of .Well Casing <br /> Domestic/public Driven Gauge of Casing - <br />{ Irrigationravel=Pack- Depth of Grout Seal ' — _— <br /> Other �otary}, Type of GroutW s <br /> Other Other Informati n ' <br /> PUMP INSTALLATION Contractor <br /> O . <br /> Type of Pump 62z , H.P. S <br /> PUMP REPLACEMENT: /-7 State Work Done <br /> PUMP REPAIR: / j State Work Done <br /> .2ESTRUCTION OF WELL: Well Diame..ter Approximate Depth <br /> T Describe Material and- Procedure <br /> I hereby agree to Comply with all lawn ;- 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 m111 work ;on-a_new well, I wil.l.,fuxnish_the San 'Joaquin Local Health District a <br />• WELL DRILLERS REPORT of the well and notify them before putting-the--we11 in use. The above <br /> information is true to the b2es my knowledge and belief. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> *F R DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE / T 7z-- <br /> ° ADDITIONAL COMMENTS: ;I <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE -INSPECTION BY DATE <br /> CALL FOR A GROUT, IN PECTION PRIOR TO PROUTING <br /> FINAL IN PECTION.,e,,,a „bc,�litcc X <br /> 11 H 14 26 y A-4-,f r"'�Gl`. ", �•r P A' �e d6� Ani X;-;.7/23,A,1,M,0 e `" <br />