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`.SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR 0 FICE USE: 1601 E. Haxelton•`Ave.., 'Stockton, Calif. <br /> Telephone.�- "(209)- 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ,,Z-4243 <br /> THIS -PERMIT EXPIRES -1YEAR FROM DATE ISSUED D4 e Issued <br />` "(complete In •Triplicate) <br /> Application is hereby made to the^,San' Joaquin'Local' Health District 'fo a permit to construct <br /> and/or install the work herein described. This application is` md a i' s:-coinpliance:with San Joaquin <br /> County Ordinance No. 1862 and the• Rules `and Regulations of the Sari Joaquin,LocAI' Health District, <br /> JOB ADDRESS/LOCATION A , 04 <br /> CENSUS,TRACT <br /> c1 <br /> owner's Name w ( _ a' a ; CD ... . . Phone <br /> E Address -0)0,:? y �. P City-_-_j . <br /> ' <br /> Contractors Name License �� T 7�0 <br /> 1 %2� ? ;.Phone �,3� �;1 <br /> TYPE OF WORK (Check) . NEW WELL/�/ DEEPEN /_/ RECONDITION ./_7 DESTRUCTION /-7 <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 WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial X Cable Tool 3 Dia. of Well Excavation 1 <br /> Domestic/private Drilled Dia. of Well Casings /( <br /> Domestic/public Driven Gauge of Casing e <br /> F Irrigation Gravel' Pack Depth of Grout Seal 7 <br /> ` Other t Rotary Type of Grout <br /> Other Other Information <br /> 1 <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work. Done <br /> PUMP' REPAIRw"'""�" ;,�: / /��S't�e Woo Done, <br /> is <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, T 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 /> g information is true to the best of my knowledge and belief. <br /> {f SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> iAPPLICATION ACCEPTED BY � DATE / r 7� <br /> ADDITIONAL COMMENTS: <br /> j PHASE I OUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE '2-'-(3` gINSPECTION BY ` 1 DATE =-_7 - 2 <br /> CALL FOR A GROUT.,INSPECTION .PRIOR•TO GROUTING AND FINAL INSPECTION.. <br /> E H�1426 ; 7/72 1M <br />