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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> O-FOFFICL' USE: 1601 E. Razelton Ave. , Stockton, Calif. <br /> Telephone: - -(209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. PW- 25S-Al <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued _4--1r-,7V <br /> �1.$•'?�"1' .7y-o-d ..• (Complete In Triplicate) N = 00 0'7c) -- o/ <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. 1`86'2 and the Rules and Regulations of the San Joaquin. Local Health Dis4rict. <br /> JOB ADDRESS/LOCATION �J. got&V •e CENSUS TRACT <br /> Owner's Nam 12Phone <br /> Address A). City <br /> Contractor's Name .(,IC License /t Phone ^� <br /> TYPE OF WORK (Check): NEW WELL DEEPEN / / RECONDITION /_7 DESTRUCTION /? { <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT / <br /> Other -/ / <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 � Caable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing m <br /> Domestic/public Driven Gauge of Casing �— <br /> Irrigation i Gravel Pacts Depth of Grout Seal <br /> Other i - Rotary Type of Grout <br /> Other Other Information <br /> k <br /> ' f <br /> PUMP INSTALLATION: Contractor R.P. <br /> Type of Pump <br /> PU2SP REPLACEMENT: / / State Worts <br /> _ <br /> PUMPS PA�r /7 State Work Done t <br /> Approximate Depth <br /> 3RqTit..... N_ OF WELL: Describe MateWell rial and Procedure <br /> ''I aquin <br /> ca <br /> lth <br /> ric <br /> I hereby agree to comply with all laws todor regulatingof the'construcSan J tion.�WithinaFIFTEENtDAYS <br /> and the State of Cal I will furnish the San Joaquin Local Health District a <br /> after completion of my work on a new �re11, The above , <br /> HELL DRILLERS REPORT of .the well and notify them before putting the well in use• <br /> information true to the be of my-knowledge and belief. <br /> TITLE F i <br /> SIGNED DRAW T PLAN ON REVERSE SIDE <br /> OR DEPARTMENT USE ONLY <br /> PHASE I DATE <br /> APPLICATION ACCEPTED .BY <br /> ADDITIONAL COMMENTS: PHASE III/FINAL IIISPECTION <br /> PHASE I1•G wi__ INSPECTION INSPECTION BY /�� DATE <br /> INSPECTION BY DATE .5--,i--!20- <br /> CALL FOR A GROUT INSPECTION PRIOR To GROUTING AND FINAL INSPECTION. /7 <br /> F. H 1626 <br />