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r <br /> r <br /> R <br /> w <br /> SAN JO,AQUIN LOCAL HEALTH DISTRICT <br /> FOF.;OFFICE USE:. 1601 E. Hazelton Ave. , Stockton, Calif. <br /> � ` ZZ <br /> b Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> z_- <br /> THIS PERMIT. EXPIRES I. YEAR FROM DATE-ISSUED Date Issued,!. .-1 73 <br /> > a <br /> . (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 in compliance with San Joaquin <br /> County Ordinance' .No. 1862 and the Rules and-Regulatigns of the San Joaquin Local. Health District. <br /> JOB ADDRESS/LOCATION. ' . / A An Ct,/a yam+ CENSUS TRACT <br /> Owner's Name r Phone <br /> Address y .. % City' ' <br /> Contractor's Name License # /�j�gi �Phone ' Z -7G 2 6 <br /> TYPE OF WORK (Check) NEW WELL/ J DEEPEN/ / RECONDITION /_/ DESTRUCTION /? <br /> AL <br /> PUMP INSTLATION PUMP REPAIR / / PUMP REPLACEMENT /_ <br /> ,Other ./—/ <br /> ---- <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY \ <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL 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 <br /> Other Other Information ' <br /> Contractor i <br /> PUMP INSTALLATION:f Type of Pump H.P. <br /> 00, <br /> PUMP REPLACEMENT: State Work Done <br /> i PUMP--*ffil4AW. State Work Done j' �e" <br /> f DFRTRUCTION OF WELL: Well Diameter 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.Cali,fornia pertaining tb 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 �owle belief. <br /> SIG D � � TLE �.►+�;,�, . ., .__ <br /> W PLO PLAN ON R SE SIDE) <br /> j. FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE - •')3 <br /> ' ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY I 4 DATE la=- 13 <br /> CALL <br /> FOR-A.-GROUT INSPECTION PRIOR TO"GROUTING AND"ftINAL INSPE ION. //(/ <br />