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SAN JOAQUIN LOCAL HEALTH DISTRICT + <br /> FOR OFFICE USE: v 1601 E. HazeitoaoAve. , Stockton, Calif <br /> Telephone: (209) 466-6781 ` <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ZZL 6150 <br /> D Date Issued /�7� <br /> THIS PERMIT EXPIRES 1-YEAR FROM DATE ISSUE <br /> AV". - (Complete In Triplicate} ; <br /> Application is hereby made to the San Joaquin Local Health District far a permit to construct <br /> d. This application is made in compliance with San Joaquin` <br /> and/or install the work herein describe <br /> County Ordinance' No. 1862 and the ules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT Z�'-- �o3p of <br /> Owner's Name Phone <br /> City <br /> Address a �v Cam Jc <br /> License # Phone k-q •-7�`7d <br /> Contractor's Name - - <br /> TYPE OF WORK (Check): NEW WELL / DEEPEN / / RECONDITION I�T DESTRUCTION /� <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /� O.. <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 � .xCable Tool Dia. of Well Excavation 1 ' <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing DRAW <br /> Irrigation Gravel Pack Depth of Grout Seal ' lr <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. m <br /> F <br /> t PUMP REPLACEMENT: / / State Work Done ' <br /> PUMP REPAIR- / / State Work Done <br /> .DESTRUCTION 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 <br /> information is true to the best of my knowledge and belief. .`. <br /> TITLE <br /> SIGNED <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE- ONLY <br /> PHASE I DATE jo <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASON <br /> E III FINAL INSPECTI <br /> INSPECTION BY/d /d' . DATE -4 -? r' INSPECTION BY v� - _ DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. 7/72 1M <br /> s . E H 1426 <br />