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SAN AQUIN LOCAL HEALTH DISTRICT Y <br /> FOF.:OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif., <br /> Telephone: (209) 466-6781 £ <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT PermiC-No: ;79-= 9 6/0 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued /-/v - 7S-- <br /> (Complete <br /> S~(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 incompliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 14iod f A % yj ' CENSUS TRACT <br /> Owner's Name Phone <br /> Address City <br /> Contractor's Name License # Phone <br />�ry TYPE OF WORK (Check) : NEW WELL/ / DEEPEN '/ / RECONDITION '/ / DESTRUCTION /_7_ y <br /> PUMP INSTALLATION /A4- PUMP REPAIR/ / PUMP REPLACE : NT / <br /> O they'� /6:f <br /> DISTANCE TO NEAREST: SEPTIC� TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> b • <br /> F INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS S� <br /> Industrial Cable Tool Dia. of Well Excavation � I <br /> Domestic/private Drilled Dia. of Well Casing <br />€. Domestic/public Driven Gauge of Casing v <br /> -1----irrigation Navel Pack Depth of Grout Seal `y1' <br /> Other 11 Rotary Type of Grout <br /> i Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: f / State Work Done <br /> f`r PUMP -tEPAIR• / / State Work Done <br /> ,DFSTRUCTION OF WELL: Wo-11 Diameter , Approximate Depth <br /> r Describe Material and Procedure. <br /> y <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 an a new well., I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and 'noti€y them before putting the well in use. The above f <br /> information is true to the best of my knowledge and belief. <br /> SIGNED �c.�+p _ _ TITLE <br /> I 1. (DRAW PLOT FLAN ON REVERSE SI E) <br /> ! FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> I APPLICATION ACCEPTED .BY DATE ( J r <br /> f ADDITIONAL" COMMENTS: 3 <br /> PHASE T1 GROUT INVECTION PHA5E I/FINAL INSPECTION <br /> INSPECTION BYlyj I.C6. D TE INSPECTION BY . DATE <br /> - CALL FOR A GROUT INSPECT N PRIOR TO GROUTING AND FINAL INSP ON. <br /> E H 1426 5/731M <br />