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V i/ ALTH DISTRICT <br /> SAN JOAE}UIN LOCAL HE <br /> FOF":0 �. .USL: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> k Telephone: (.204) 466-6781 f <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. _t5l5l `&1 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued R/.1-- 76 <br /> F 0 (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to :constr.uct <br /> and/or install the work herein described. " This application is made in compliance w1th San Joaquin <br /> I County Ordinance-.No: 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION _ +- ! CENSUS TRACT ' <br /> 1€ 0 <br /> jOwner's Name % Phone <br /> Address ~ x ' City <br /> Contractor's Name License JyVhan <br /> TYPE. OF WORK (Check) : NEW .'WELL / DEEPEN17 RECONDITION /_/ DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR"/ I PUMP REPLACEMENT /-7 <br /> Other l / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE T'-'PE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> --:4Domestic/private -y Drilled Dia. of Well Casing <br /> Domestic/public F Driven Gauge of Casing <br /> Irrigation Gravel Pack 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 /> ri <br /> 'P PUMP REPLACEMENT: / / State Work Done <br /> PUMP nPAIR: / / State Work Done <br /> .DRCTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> r� <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 s <br /> i 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 /> �4 <br /> '•# SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> p FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ° ADDITIONAL COMMENTS: � <br /> ' P SE II GR0�3T INSPECTION PRASE IIT/FINAL INSPECTION <br /> INSPECTION BY DATE .� 17 7 INSPECTION BY DATE—� <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING .AND FINAL INSPE <br /> F.--14,11,?r, 51731M <br />