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kk 0 <br /> SAN JOAQUIN-LOCAL- HEALTH DISTRICT � <br /> FOR OFFICE USE: {/ 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 3- 0 S U) <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued $'-[ <br /> - (Complete In Triplicate) il <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 an_ the Rules and Regulations/f t]�e San Joaquin Local Health District. G° <br /> ow-_711 -F 'C�e <br /> .FOB ADDRESS/LOCATION -9-0-S-e1c1-a6 <br /> CENSUS TRACT <br /> Owner's Name Phone <br /> Addressl f/l�'l i �a2e�wyy. 1 - - City ���-✓ <br /> Contractor's Name License #E 1,2 aZ2i Phone ,5VO <br /> TYPE OF WORK (Check): NEW WELL /,�/ DEEPEN /_/ RECONDITION /_� DESTICUCTION /� <br /> PUMP INSTALLATION /—/ PUMP REPAIR /—/ PUMP REPLACEMENT /7 <br /> Other L-1 Q� ,4 iT-42,Q - <br /> DISTANCE TO NEAREST: SEPTIC TANK a� SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS (N <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 /> I <br /> I <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: 17 State Work Done <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, 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 TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br />' APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II 9ROUT I PECTIO PHAS III/F NAL INSPECTION <br /> INSPECTION BY DATE y 7 INSPECTION BY DATE p <br /> CALL FOR A GR T INSPECTION PRIOR TO GROUTING AND FINAL INSPECTI . <br /> E H 1426 7/72 1M <br /> r <br />