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C)� SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> I�p Oi FICE IASL': 1601 E. Hazelton Ave. , Stockton, Calif. <br /> t - Telephone.:. (209) 466-6781 3 <br /> - APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ]4�f_�lJ , <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued _8'-76 <br /> (Complete In Triplicate) <br /> . Application is hereby rade to the San Joaquin Local Health District for a permit to construct <br /> sand/or ir:stall the works herein described. - This application is made in compliance with Sart Joaquin <br /> County Ordinance No. 18.62 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB. ADDRESSILOCATION <br /> J CENSUS TRACT <br /> 00 Phone I 4 <br /> Owner's Name �� � V - <br /> - Address City <br /> ...Ccntractor-'s Nam <br /> _License] 7 Phone, <br /> 1 <br /> TYPE OF WORK (Check) . NEW 14ELL /�EEP;EN ',/�/' RECONDITION / / DESTRUCTION <br /> PUMP INSTALLATION /Z/,, �U'M'MP 'REPAIR / / PUMP REPLACEMENT I T <br /> Other <br /> ISTANCE 'TO NEAREST: SEPTIC TANK _J /- SEWER LINES PIT PRIVY <br /> tEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> ► INTENDED USE TYPE .OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial " "' !_.—_'Cable Tool Dia, of We11 Excavation <br /> /,---Domes tic/private:. <br /> Drilled <br /> Dia. of Well Casing A <br /> Domestic/Public ,Driven Gauge of Casing <br /> Irrigation) �. Gravel Pack Depth of Grout Seal (� <br /> Other ' ' Rotary Type of Gro�x' - ` <br /> i a : -Other Other information <br /> TUIV INSTALLATION: Contractor ' I.. <br /> _.�. P <br /> Type of Pump <br /> r ? <br /> PUMP REPLACEMENT: / / S tate Work Done <br /> .:f',.�- - - +-•�.... . � .._ + ,.r ._,sem.. .� f �...�+..��� r• �N� 1 <br /> PUiPAIK:_ 1, / State Work Done '� �►` 1 <br /> .'w Approximate Depth <br /> :, FCTRUCTION, OF WELL: Well Diameter pp <br /> Describe Material and Procedure <br /> ' Ihereby agree to comfly with all laws and regulations of the San Jaaquin Local Health District <br /> and the State of California pertaining to or regulating well "constructiou. 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 /> a information is true t8 the best of my knowledge and belief. <br /> �M <br /> SIGNED ' TITLE <br /> E. X (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> } APPLICATION ACCEPTED pBY DATE <br /> ADDITIONAL. COMMENTS: <br /> PHASE I GROUT INSPECTION PHASE III/FINAL INSPECT IN / <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO -GROUTING AND,:FINAL INSPECTION. <br /> Ll- u 'It�� <br />