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SAN' JOAQUIN LOCAL HEALTH DISTRICT <br /> COI. OI'FICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. _ 3. -P, <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. `] . <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued - 0- 75� i <br /> ',' (Complete In Triplicate) <br /> Application is hereby made ;'po- 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. 186 And the Rules and Regulations of the- San Joaquin Local Health District. <br /> ,TOB ADDRESS/L&CATIO-"I �c�'V'./ CiCJ� �/v Z�'/7V� CENSUS TRACT <br /> a .. <br /> Owner's Name �~ d J Phone ' <br /> t <br /> ' Address �� City � <br /> Contractor°s Name .L`�' /�JJ� S License -323.PboneA"�J� <br /> 4 5;0'' _ <br /> TYPE OF WORK (Check) : NEW WELL. DEEPEN /_/ RECONDITION /' / DESTRUCTION V� <br /> PUMP.' INSTALI:ATION / / PLTMP PAIR % / PUMP REPLACEMENT <br /> Other / / D ', <br /> DISTANCE TO NEAREST: SEPTIC. TALK EWER LINES PIT PRIVY-` <br /> SEWAGE. D.ISPOSAL FIELD CESSPOOL/SEEPAGE PI '. OTHER <br /> IUENDED USE TYPE OF WELL CONSTRl7C.-T.10N SPECIFICATIQNS <br /> I dustrial Cable Tool Dia. of Well E*cavation <br /> DAmestic/pr-ivate'R ' Drilled Dia. of Well Casing _ <br /> Domestic/public Driven Gauge of Casing ; / <br /> Irrigation Gravel Pack Depth of Grout Seal' ' C"1 <br /> Other Rotary f. Type of Grout /� 1 <br /> Other ,k>• Other Information ' <br /> PUAB.' INSTALLATION: Contractor <br /> Type of .Pump H.P. <br /> PUMP REPLACEMENT: State Work Done <br /> PUMP TZEPAIR: / / State Work Done <br /> j <br /> ,DFGTRUCTION OF WELL: Well Diameter � -- - - - - Approximate Apth <br /> Describe Material and Procedure: "r <br /> I hereby agree to comply with all laws and regulations of the aaqtfiTOzct <br /> and the State of California pertaining to or regulating well ''construction. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish the Sari 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 my knowledge and belief. <br /> t <br /> SIGNED I [}�}dot �??. 1ra nj),_AAr TITLE <br /> (DRAW�PLOT PLAN ON REVERSE SIDE) <br /> R DEPARTMENT' U.SE ONLY <br /> Z PHASE I _ <br /> APPLICATION ACCEPTED .BY DATE <br /> ADDITIONAL, COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTI N s i <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> i' CALL FOR A GROUT INSPECTION PRIOR TO,--GROUTING AND"FINAL INSPECTION. <br />