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i <br /> SAN, JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton: Ave. , Stockton, Calif. <br /> Telephoner (209) 466-6781 <br /> PLICATION FOR WELL CDNSTRUCTION OR PUMP PERMIT Permit No: Zw <br /> THIS PERMIT EXPIRES '1 YEAR FROM DATE ISSUED Date Issued:. _7 Zi <br /> -+1 -(Complete In. Triplicate) " r <br /> Application is here made San Joaquin Local HealthD`istrict for a'$peritit to construct <br /> s' and/or install the work herein described. This aRplicati6n' is made in ,c`ompliance with San Joaquin <br /> County Ordinance No. 1862-arid -the. Rules: and Regu itions pf the San Joaquin Local Health District. , <br /> 1110 'oe <br /> JOB ADDRESS/LOCATIONA=AE"o ,tCENSUS 'TRACT <br /> Owner's Name r' Cr m, ��. .,qc k. 4✓ . <br /> Phone ---NtJ .ph L� I <br /> Address :City;. <br /> _ <br /> Contractor's Namet 3`y ob <br /> License # l2d ► Phone <br /> y <br /> TYPE OF WORK..(Check-) f­ NEW WELL 1)27, DEEPEN /_/ RECONDITION /_7 DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /7 ; <br /> Other /% — — REPLACEMEN — <br /> DISTANCE TO NEAREST: SEPTIC .TANK SEWER- <br /> UPN' -f ,�: p� PRIVY <br /> SEWAGE DISPOSAL FIELD EEPAGE PIT OTHER <br /> t y <br /> INTENDED USE TYPE-OF WELL CONSTRUCTION SPECIFICATIONS' <br /> Industrial , Cable Tool Dia. of Well Excavatidn. <br /> Domestic/private Drilled _ Dia, of Well Casing 2 . ;"; Pr <br /> Domestic/public. Driven Gauge of Casing <br /> Irrigation g g �._,_ r1 ' <br /> g Gravel Pack Depth of Grout Seal <br /> S-2Other Rotary Type of Grout 19, <br /> Other Other Information <br /> PUMP INSTALLATION: : . Contractor � � <br /> Type of Pump.. ., n H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State .Work Done C. <br /> ESTRUCTION 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 /> SIGNED wr�yirt3 TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE ! ' <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE,.III/FINAL INSPECTION, <br /> INSPECTION BY DATE INSPECTION BY DATE 2 2__ <br /> CALL FOR A GROUT..INSPECTION_PRIOR TO GROUTING AND FINAL INSPECTI . <br /> E H 1426 y y 4e: 7/72 1M <br />