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Ly <br /> rr ` ' <br /> SAN 'JOAQUIN LOCAL HEALTH DISTRICT <br /> Szor. OF ICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> I� Telephone: (209) 466-6781 <br /> I APPLICATION FOR WELL CONSTRUCTION OR PUMP ]HERMIT Permit No. • 3-s 6 0 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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 made in compliance with San Joaquin <br /> County Ordinance No. X 2 ani the Rules and .Re Mations of the Sap Joaquin Local Health District. <br /> �d Karl"- �� e� � <br /> JOB ADDRESS/LOCATION CENSUS TRACT " S <br /> Owner`s Dame , > ; . �2 Phone <br /> / <br /> J/ 1 <br /> Addss ` _ r > City G�j �c C� <br /> r <br /> t <br /> Contractor's Name (U [�iL ,,. �lr. ,� ,� ,,►,r,� License #IZIZ2.32 Phoneg72_1- <br /> TYPE_OF WORK- '(Check)-: zNEW WELL:./ J _:DEEPEN%4_7--..RECONDITION I�.I -.DESTRUCTIONJ T. <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other J / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER' LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> ' INTENDED USE TYPE OF ITELL CONSTRUCTION SPECIFICATIONS ' <br /> Industrial Cable Tool Dia. of Well Excavation ' 9 <br /> :.Vy Domestic/privateDrilled Dia. of Well Casing f ' <br /> Il'_ Domestic/public Driven Gauge of Casing <br /> '11 Irrigation Gravel Pack Depth of Grout Seal <br /> iS Other V Rotary Type of Grout <br /> Other Other Information <br /> -PUME INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP 'IEPAIR:. { / State Work. Done <br /> .pF,_RUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I Yiereby 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 /> in11rmation is true to the best of my knowledge and belief. <br /> SIGNED TITLE �77�.�,�Ql! , <br /> IN. (DRAW PLOT PLAN ON REVERSE SID <br /> Fa D TMENT USE ONLY , <br /> PHASE I <br /> APPLICATION ACCEP Y DATE I� <br /> ADDITIONAL COMMENTS: { <br /> PHASE II,GROUT INSPECTION I IAL INSPECTION { <br /> INSP ECTION .BY �`,�r� DATE Ij 3!- INSPECTION DATE -�Z2- <br /> IfCALL F'0 A GROUT. INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> Cr. rr I r.r)r 1� /711m <br />