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i F < <br /> SAN JOAQUIN LOCAL,HEALTH DISTRICT <br /> OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. ,f97w <br /> Telephone! (209) 466-67.81 <br /> ' .APPLICATION FOR WELL CONSTRUCTION;OR PUMP. PERMIT :Permit No. 1/- <br /> THIS PERMIT EXPIRES l YEAR FROM.DATE ISSUED Date Issued /`�_,7 <br /> i , a {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 worC herein described. , This application is made in compliance with Saxe Joaquin <br /> County Ordinance .Nu. =1862 and the .Rules„and Regulations of the San Joaquin Local stealth District. <br /> JOB ADDRESS/LOCATION, ..�// d 4 Moo? `�4-e�4c 4� i! /�`f/e __ _ CENSUS TRACT <br /> Owner's Name /LPhone. <br /> 4 Address �. �. ~--�>:�:� y`~:-. �m x. _ City <br /> _ f <br /> S License JI/ <br /> ?hone jy 74 �h <br /> Contractor's Name , a <br /> f NEW WELL / / DEEPEN.:,/ / RECONDITION /_/ DESTRUCTION /7 <br /> TYPE OF WORK (.Check): <br /> PUMP INSTALLATION tl - PUMP REPAIR-/ / PUMP REPLACEMENT -7 <br /> Other ./ / <br /> t DISTANCE TO NEAREST SEPTIC TANK SEWER~LINES PIT PRIVY <br /> j - SEWAGE DISPOSAL' FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial -Cable Tool Dia. of Well Excavation <br /> r]� Domestic/private: 'Drilled Dia. of Well Casing <br /> Domestic/public' Driven Gauge of Casing <br /> Irr'igat'ion f Gravel Pack Depth of Grout Seal <br /> Other- u - Rotary . Type of Grout <br /> IM Other Other Information <br /> PUMP INSTALLATION::- 'i Contractor <br /> Type of Pump H. <br /> PUMP ,T: I A/ State Work. Donetl� , "I <br /> _ - <br /> PUMP REPAIR: ii . /- / State Work Done Awl <br /> i .t <br /> DFRTRUCTION OF WELL: Well Diameter. Approximate Depth <br /> 1 DD. escribe Material and Procedure <br /> I hereby agree to coin ly with all s and regulatfions of the San Joaquivf Local Nealth District. <br /> and the State of.Calikornia 'pertaini.ng„ 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 .the well and notify them before putting the well in use. The above <br /> information is true..to the best o dge belief. <br /> SIG ED ITLE dl' <br /> 7 R_A PL T. PLAN ON RIWERSE. SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> t. PHASE -I i 3 / <br /> ?; APPLICATION ACCEPTED BY DATE 2i <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASA III/P NAL INSPECTI N <br /> INSPECTION BY DATE INSPECTION BY DATE. <br /> i CALL I'ORvA GROUT INSPECTION PRIOR TO•oGROUTIN.G.AND FINAL INSPECTION. <br /> F N 142E ._ 7 1M --- <br /> I�. <br />