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Nil <br /> ~ Y 2. SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR FFI� s USE: 1601 E. Hazelton Ave. ,,'Stockton, Calif. <br /> �1. <br /> Telephone- (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Z <br /> a , <br /> ` THIS PERMIT EXPIRES .! YEAR FROM DATE ISSUED , Date I sued <br /> (Complete Ih Triplicate) E <br /> Application hereby made to the San Joaquin Local Health District for a permit t construct ! <br /> and/or install the work herein described. This application is made incompliance ith San Joaquin i. <br /> County Ordinance No. 1,862 and the Rules and Regulations of the San Joaquin Local H alth District. � <br /> JOB ADDRESS/LOCATION ` 4 c [� � j'L- --- CENSUS TRACT <br /> r C Vii` <br /> Owner's Name C[�/ Phone- ^ l c <br /> f' <br /> f; <br /> Address <br /> City 7'G <br /> Contras for s Name S�_1 � l« License IL27�3a3 Phone �-f <br /> TYPE OF WORK (Check) : NEW WELL;�C DEEPEN '/—/ RECONDITION -/-7 DESTRUCTION /� <br /> PUMP INSTALLATION' 'PU,IP'REPAIR'`/ /' PUMP REPLACEMENT <br /> Other /% <br /> DISTANCETO NEAREST;. SEPTIC TANK SEWER LINES PIT PRIVY <br /> " SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER f. <br /> -----In <br /> USE TYPE OF WELL CONSTRUCTION .SPECIFICATIONS <br /> IndustrialCable 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 S p <br /> Other Rotary Type of Grout <br /> Other Other Information ' 4C } <br /> PUNP INSTALLATION: Contractor ez, <br /> Type of Pump z <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> ,DESTRUCTION OF WELL: Well Diameter _ __ _ „ <br /> 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 /> 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,,t4n well and notify them before putting the well in use. The above <br /> information is true Dest knowled a and belief. <br /> SIGNED n _� TITLE d�- <br /> RAW PLOT PLAN ON REVERSE SIDE <br /> o <br /> PHASE T FOR DEPARTMENT USE ONLY ; <br /> � <br /> APPLICATION ACCEPTED BY DATE -�3- <br /> ADDITIONAL COMMENTS: <br /> PHAS II GROUT INSPECTION PHASE LIZIFINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE ` <br /> CALL FOR A OUT INSPECTION PRIOR TO GROUTING AND FINAL INS ON. <br /> EA 1426 4/72 l� <br />