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A: <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> TOF- OF ICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> .°-ub � Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. -, ( /)4 <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED Date Issued �2 x_73 <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit- to construct 1 <br /> and/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 District. <br /> �J r � � <br /> JOB ADDRESS/LOCATION d" W o. d e) CENSUS TRACT <br /> Owner's Name c Phone ' <br /> Address 7/ l.cm3 te. ptt -,P;k ge City V jVC- <br /> Contractor's Name V/Vtic' License # `�37Phone � 76 <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN /-7 RECONDITION /—/ DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other / / W f a4tda i Xg>o <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 Cable Tirol Dia. of Well Excavation <br /> >' Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven ;' Gauge of Casing ' <br /> Irrigation Gravel Pack f- Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: State Work Done eu- <br /> PUMP UPAIR: / / State Work Done <br /> BFgTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <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 San Joaquin Local Health District a# <br /> WELL DRILLERS REPORT of the well and notify them before putting the well in use. The above s <br /> information is true to the best of my knowledg nd bel ef. <br /> 4 SIGNETITLE <br /> p RAW LOT PLAN ON RKLNVERsE SIDE;) <br /> K FOR D4WTMENT USE ONLY <br /> 4, PLICATION ACCEPTED BY �' DA <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION WPHA44-�fNSPECTION <br /> INSPECTION BY DATE INSPECTION BDATE <br /> CALL FOR A GROUT-INSPECTION PRION. TO GROUTING AND FINAL INS / ; <br /> 5/731M <br />