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_ � R <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> TOT.-OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77 5-e 34c) <br /> THIS PERMIT EXPIRES 1 REAR 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 /> avid/or install the work herein described. ' This application is made in compliance with San Jbaquinl <br /> County Ordinance No. 1862 and the Rules and Regulations of the' San Joaquin Local Health District. ¢ <br /> oY �. Np V-J-.A or 5pu,rk cN© �2Woo o K p, <br /> JOB ADDRESS/LOCAT'IO�j CENSUS TRACT <br /> Owner's Name A oew.. NYS $ - Z.3f��-j <br /> Phone ' <br /> ZZZ S-7 * <br /> Address City " <br /> Corttractox's Name (YWk "�' <br /> -t.� '� "C .u�4�, License # l05RfZ Phone <br /> TYPE OF WORK (Check) : NEW WELL / J DEEPEN- /_/ RECONDITION / J DESTRUCTION 1 <br /> PUMP INSTALLATION / / PLW REPAIR/ / PUMP REPLACEMENT /- <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVYi apo' <br /> .. SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL <br /> CONSTRUCTION SPECiFI ONS <br /> Industrial. 41�_ Cable Tool Dia. of Well Excavation <br /> Domestic/private _ Drilled Dia. of Well Casing <br /> ..._, �. <br /> Domestic/public Driven Gauge of Casing <br /> . Irrigatiori GravelPack 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 UPAIR: <br /> f / State Work Done <br /> ,DFCTRUCTION 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 /> of er completion of my work on a new well, I will furnish the San Joaquin Local Health District a � <br /> 14BAL DRILLERS NEPORT of the well and notify them before putting the well in use. The above <br /> informs 'on i rue o th best of my knowledge and belief. <br /> Lc'S �Ep <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY E <br /> P1dASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL' CONIMENTS: t <br /> PHASE II GROUT INS ECTION PHASE IT. FINAL NSPECTION <br /> INSPECTION,BY DATE , INSPECTION BY �DATE 2 <br /> . CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E. H 1426 c�/7'1iM <br />