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3 _ _.... SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO 12 OFFICE USE: 1.601 E. Hazelton Ave. `Stockton, Calif. <br /> • <br /> Telephone: (209) -,466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION.'.OR PUMP PERMIT Permit No. Z7 d <br /> THIS PERMIT :.EXPIRES _l'YEAR'•FROMt.DATE ;ISSUED', , Date- Issued Y3Y3 y i <br /> (Complete In.>Triplicate) ✓�: 1 r Q05= 3�b—Y1� 7 jii <br /> App lication reby_-made ito .thewSan: Joaquin.Local Health District-for: a permit to construct i <br /> and/or install the work herein described. This+-application.is_:made'in ,compliance with San Joaquin j' <br /> County Ordinance No n1862randkthe .RUies and .Regulations` of-the San ,Joaquin Local Health District. € <br /> vf}1 #' t .. 76V. rt; i :.'.. p.:'r ;. *: „' .•.!,x c;,i:.-E <br /> JOB ADDRESS/LOCATIONi ..� .p -E � � /�.r`�/�' �1I"Z( 1\ + CENSUS .TRACT` S `�` ''- <br /> .'�':.1�'C <br /> Owner:s' Name;=f.*/U�:-Q_ [iT '0�,�; .��n~ r�=�s � . �� g �� Phone�3( <br /> t <br /> Address a �, �, C 6 C� Cit <br /> -- _ L <br /> _ 3 <br /> Contractor's Name( � � ..�� „ _ _......_.. .,_.___„ License �� Z_C_ hone S/y <br />,:_TYPE_OF WORK (Check) := - NEW RECONDITION I_� DESTRUCTIQN"%��� Tom_ �� <br /> PUMP INSTALLATION/ / PUMP REPAIR/ / PUMP REPLACEMENT /-7 <br /> Other. <br /> DISTANCE TO NEAREST: SEPTIC TANK 7 ::S:_ SEWER LINES PTT PRIVY • •_ <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER � ? <br /> ' J <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> industrial. Cable Tool Dia. of Well Excavation <br /> omestic/private Drilled Dia. of Well Casing i <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 /> 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 /> SIGNED ( y.1 - � ) � � - - TITLE - - <br /> (DRAW PLOT PLAN ON REVERSE SIDE) A <br /> POR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION F PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE ' p <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H'1426 .g .,. ._ ._...._ �� ._. . . 4/72 1M <br />