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SAN JOAQUIN LOCAL HEALTH DISTRICT /� w�c <br /> FOR U 1601 E. Hazelton Ave. , Stockton, Calif. SCANNED <br /> Telephone: (209) 466-6781 <br /> PLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 6 - L -� 3 <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. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 00 � CENSUS TRACT <br /> Owner's Name 100yQ ,0�1 C / ! Phone <br /> Address 10 L) Lt„a (..ca t L 1 0 po 4 City 7104 <br /> Contractor's Nameit� �4 License #/ 3 YJ'Phone t/jt� <br /> TYPE OF WORK (Check): NEW WELL / / DEEPEN / J RECONDITION /-7 DESTRUCTION /-7 <br /> PUMP INSTALLATION /—/ PUMP REPAIR X/ PUMP REPLACEMENT /7 <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY e.. <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER o <br /> .. <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation le <br /> Domestic/private _ Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation E rro- Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor ��T-8 w <br /> Type of Pump ,$ AM dhSI H.P. <br /> / <br /> PUMP REPLACEMENT: /% State Work Done <br /> PUMP REPAIR: State Work Donej � <br /> V <br />,DESTRUCTION OF WELL: Well Diameter ' Approximate Depth , 6r <br /> Describe Material and Procedure <br /> L� <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 , LE <br /> ZI <br /> DRAW P ON REV SE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: 44 <br /> PHASE II ROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY -� DATE INSPECTION BY e DATE /3 <br /> CALL FOR A GRO T INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />