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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> UF. OFFICE USE: 1601 E. Hazelton Ave., Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 75--Te4 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ?<S'- <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 Joa uin Local Health District. <br /> JOB ADDRESS/LOCATION fit- t/ IBJ �-a� �� cDN � ENSUS TRACT <br /> Owner's Name �8- ! -� /J�J Phone <br /> 1 .--cam' !� <br /> Address City�---��, r/ _ <br /> Contractor's Name Z�� f' zi License/4 0 373 Phonwtg 6 <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN(_/ RECONDITION /_/ DESTRUCTION /^T <br /> PUMP INSTALLATION / / PUMP REPAIR PUMP REPLACEMENT /? <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY pQ <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PTT OTHER /Z <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 /> PUMP REPLACEMENT: / / State Work Done <br /> _ r <br /> PUMP 'tEPAIR: State Work D <br /> DF�TRUCTION 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 (� bn/� �d2• Xy►�twyy- TITLE <br /> (DRAW PLOT PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PiIASE I <br /> APPLICATION ACCEPTED BY DATE <br /> IFI� 244) <br /> ADDITIONAL COMMENTS: 17 <br /> PHASE II GROUT INVECTION PHASE FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY 11Z DATE Z�:2d —ZS <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 5/731M <br />