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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: i 1601. E. Hazelton Ave. , Stockton, Ca' lf . <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRI'MON OR i'UMP PERMIT Permit No.�s. 11/94' <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 1Z 7T <br /> (COr.plete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> .end/or install the work herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health ristrict. <br /> JOB ADDRESS/LOCATION �_�1��],6���C_,�c� �U CENSUS TRACT _7" <br /> fNner's Name. --- _ <br /> Phone <br /> Address JJ- y 9 •- til�t City <br /> --- <br /> Contractor's Name =.�J2�1 -- License t// Phone <br /> TYPE ()F WOR:; (Check.): NEW WELL IjEEI'I:N /7 RECONDITION /-7 DESTRUCTION /- <br /> PUMP INS .ATION /-7 —PUMP REPAIR /-7 P" REPLACEMENT /7 <br /> Other <br /> DISTANT:'. TO NF.ARF.ST: SEPTIC TANK _ SEWER LINES _ PIT PRIV'f <br /> SEWAGE DISI'0�11. FI":LD CESSPOOL/SF.EPA-E PIT OTHER <br /> INTENDED USE TYPE OFWELL CONSTRUCTION SPECIFICATIONS <br /> Industrial _ CL41e Tool Uir. of Well Excavation <br /> r Domestic/private �� Drilled Dia. of Well Casing _ <br /> _T_- Domestic/public ~ Driven Cauge of Casing _ e�S, <br /> _ Irrigation � Gravel Pack Depth of Grout Seal Cry a: <br /> Other _ 1 Rotary Type of Grout <br /> uther _ Other Infc rmation <br /> ,Y. <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / State Work Done .� <br /> PUMP REPAIR: /�j StUce 4 �rk Done _ w� <br /> ,DESTRUCTION OF WELL: Well -,(&meter Approximate Depth <br /> Denc: :oe Mnterinl end Procedure <br /> I hereby agree to comply with ell 1A`/e!id regulation, of the San Joaquin Local Health District <br /> and the State of California pertaining to or regulating well esnstruction. Within FIFTEcN r—s <br /> I will furnish the San Joaquin ical Health Distrlrt a <br /> after completion of w; work on +, new well, <br /> WELL DRILLERS REPORT of Lhe well Ind notify them before putting the well in use. The above <br /> information is Lrue to the best of My knowleJge and belief. <br /> SIGNED �l ►(�_ TITLE <br /> RAW PLOT PLAN ON REVERSE SIDE <br /> R DFS MENT USE ONLY <br /> P11ASF. T <br /> APFLIC..IION ACCF,i► BY A DATE r .73 <br /> ADDITIONAL CO <br /> E OUT INSPt:'TIOtJ P I AL INSPEC I N <br /> INSPECTiDN B ? DATF. ��,` �,� <br /> IIiSPECTI ti DATE - 73 <br /> CALL FOR A GROUT .LNSPECTION PRIOR TO GROUTING AND FINAL I%.SPECTION. 7177 lu -7 <br />