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SAN JOAQU.IN LOCAL HEALTH DISTRICT <br /> I'OF,:O1 ICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> s Telephone: (209) 466-6781 1 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Z41- 3.5_ V <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 7_9-7q- <br /> (Complete <br /> --9-7q- <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> and/or install the work herein described. ' This application`is bade in compliance with San Joaqui <br /> County Ordinance No. 1862. and the Rules and Regulations of the,'San Joaquin Local 110 alth District. <br /> JOB ADDRESS/LOCATION 47C 5SUS TRACT <br /> Phone <br /> Owner's Name <br /> Address City ' ' � <br /> Contractor's Name <br /> License_ # r. Phone. <br /> TYPE OF WORK (Check) : NEW WELL IVI�DEEPEN / / RECONDITION / / DESTRUCTION i7 <br /> PUMP INSTLATION I / PUMA' REPAIR '/ / PUMP REPLACEMENT /7 <br /> AL �} <br /> Other <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 Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> -Irrigation W__ 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 />� rye. <br /> PUMP REPLACEMENT: / / State Work Done At <br /> Ste LJnrk`'Done <br /> DFRTRUCTION OF WELL: Well. Diameter Approximate Depth - -- <br /> - - - - -- <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 <br /> information is true to the best of my knowledge and belief. <br /> SIGNED TITLE <br /> (DRAW SLOT PLAN ON REVERSE SID ) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE ' � - - 7 <br /> ' APPLICATION ACCEPTED .BY <br /> j ADDITIONAL COM1MMNTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY _ DATE ZF6 r—t-f-75/ <br /> is CALL FOR A GROUT-INSPECTION -PRIOR -TO GROUTING.-AND FINAL INSPE TION. <br /> J F 14 1 G 7 6 - 5/-/,3 IM - - <br />