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�v SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE: USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 75-�7 9fo i <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In 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 made in compliance with San Joaquin <br /> County Ordinance No. 1862 and the les and Regulations of the San <br /> Joaquin Local Health District. <br /> JOB ADDRESS/LDC ON ac-6 (/ CENSUS TRACT <br /> Owner's Name Phone 7 <br /> Address City <br /> Contractor's Name `r U /A'!pLicense �-3�Phone�� <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN -/—/ RECONDITION /_/ DESTRUCTION /-7 <br /> F PUMP INSTALLATION / / PUMP REPAIR _& PUMP REPLACEMENT <br /> i other I I <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY .� <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER pb <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 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 /> PIW REPLACEMENT: / / State Work Done <br /> PUMP ''tEPAIR: �cL'-A " <br /> a _ <br /> / State Work Do <br /> .DFgTRUCTION 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 /> SIGNEDTITLE )?1 Cvy;.r4,) <br /> (D W PLOT PLAN ON REVERSE SIDE)-- V �T <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY � � DATE <br /> ADDITIONAL COMMENTS: t _ <br /> PHASE II IN EC FHA T/FAL INSPECTIO <br /> INSPECTION BY DATE INSPECTION B '� DATE <br /> CALL FOR A GROUT INSPECTION PRIOR GROUTING AND FINAL I P CTION. � <br /> E H 1426 . _ -2 5/.7314 <br />