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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> * <br /> 1601 E. Hazelton Ave. , Stockton, Calif. <br /> FOR OFFICE USE: <br /> Telephone: . (269) 466-6781 Permit No. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> Date Issued <br /> i THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED r <br /> (Complete In Triplicate) it to <br /> ct <br /> Application is hereby ma a .l.o the San Joaquin�Local Health a perm <br /> aapplicationDistmade inrict rcompliance with nSan uJoaquia: <br /> and/or install the work .ier.'in described. PP <br /> County Ordinance No. 180 and the Rules and Regulations of the San Joaquin Local District. <br /> Health � <br /> I y �" CENSUS TRACT <br /> I Cal <br /> JOB ADDRESS/LOCATION °2 <br /> li Phone <br /> Owner's Name <br /> 40 City . <br /> Address . <br /> .f; License #/B-2-1 Phone <br /> Contractors Name <br /> TYPE OF WORK (Check) : NEWLL / / DEEPEN /7'UMP REPAIR(/NII PUMP STRUCTION REPLACE � <br /> REPLACEMENT �� <br /> PUN, INSTALLATION. /_.-- /,; <br /> k <br /> ji <br /> Other i-1 ... , <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> S WAIT E 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 64 <br /> # <br /> Domestic/public Driven Gauge of Casing 0 <br /> ' <br /> Irrigation Gravel Pack ._ Depth of Grout Seal <br /> Other _ Rotary, Type of Grout„ <br /> Other Other Information <br /> fi PUMP INSTALLATION: contractor P <br /> ,Ty'ie of Pump --e e H.P. / f <br /> _ State Work Done ! �'� X0 <br /> PUMP REPLACEMENT: IkI <br /> / 1 <br /> PUMP REPAIR: /I� State Work Done, <br /> Approximate Depth <br /> DESTRUCTION OF WELL: Well Diameter -- <br /> Describe Material and Procedure <br /> II' <br /> I hereby agree to comply 'lith 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 my1wok on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT off the well and notify them before putting the well in use. The above <br /> ` information is true to thii best of kno edge d belief. <br /> SIGNED <br /> TYLE ,�1b1' <br /> D LOT PLAN ON R SE SIDE <br /> FOR `DEPARTMENT USE ONLY <br /> PHASE IDATE <br /> APPLICATION ACCEPTED BY 'lam <br /> ADDITIONAL COMMENTS: PHASE III FINAL INSPECTION <br /> PHASE II�11GROUT INSPECTION' INSPECTION BY DATE <br /> INSPECTION BY IE U DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION, 7/72 1M <br /> E H 1426 �� �� <br />