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SAN JOAQUIN LOCAL IT,�ALTH DISTRICT <br /> FOR OFFICE USE: i601 E. Hazelton,•Ave. ,.o Stockton, Calif. <br /> Telephone:.'-- (2019),-.466-6781 <br /> PLICATION FOR WELL..CONSTRUCITION'%:OR PUMP PERMIT Permit No. <br /> z1-6 <br /> THIS PERMIT 1-EXPIRES` :1`YE RJ FROM.-DATE ISSUED' -Date.,.Issued -7 2Z <br /> M' let6lIri Tr11p-litate) <br /> P <br /> Applicati-ot)-ir,-3,h-erebyz,madex.t-o Ithe-,§anj J-oaquiTi".Lo'cal Health District-. f or: a- permit)to Construct <br /> and/or install the work herein described. This­;.app1ic:ation,is'.,,made-in,compliance with. San -Joaquin <br /> Coun tyj-Ordinance�No;-,,18 6 2 rzftd{-'th& Rul-e S-,,and,,Regula°tkons',.6 f"the San' t Joaquin. Local H,ealth District. <br /> JOB ADDRESS/LOCATION =Vr -CENSUS TRACT`- k, <br /> TO k:.4L <br /> _'­'..� <br /> Owner! �0 es'-,Name).' -5-766 f e' � iv( <br /> SPhohe <br /> 2, <br /> Address City Z.. <br /> Contractor's Name <br /> W4-Y4 1 00 P License # �666 Z Phone 41e 2 <br /> TYPE OF WORK (Check) : NEW WELL/;:TDEFP* EN '/ RECONDITION /_7 DESTRUCTION /7 -7 <br /> PUMP TNST�TLATION -/ / PUMP REPAIR PUMP REPLACEMENT <br /> Other, <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER'LINES PIT PRIVY <br /> 'SEWAGE DISPOPAL..FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE ' TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> L <br /> Industrial Cable Tool -Dia. of Well. Excavation <br /> Domestic/private Drilled -Dia. of Well Casing <br /> Domestic/public Driven Gdug6 of Casing if e <br /> irrigationGravel Pack.. Depth of Grout' Seal <br /> Other L� otary Type mof Grout <br /> Other Other Information <br /> 4• <br /> PUMP INSTALLATION: Contractor t <br /> Type of Pump <br /> PUMP REPLACEMENT: 'State Work Done <br /> PUMP REPAIR: State Work Done <br /> ,DESTRUCTION OF WELL: . Well Diameter Approximate Depth <br /> Describe MaterialandProcedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health Districtm <br /> andthe State of� California 'pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> after completion ofn <br /> . my work on anew well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notify th6m before putting.1the-well, in.-use......-The--above.. <br /> information is true tom the best of;my-knowledge and belief. <br /> SIGNED TITLE <br /> (DRAW PLOT .PLAN ON m REVERSE SIDE) <br /> �FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY 7 DATE <br /> ADDITIONAL COMMENTS:: <br /> I PHAAE IIIIFINAL INSPECTION PHASE 11 GROUT INSPECTION <br /> INSPECTION By DATE INSPECTION BY DATE jmlo,4 <br /> 7-- 1 <br /> CALLFOR A GROUT INSPECTION-PRIOR-TO..G,ROUTIN,G AND YINAL_INSPECTIO /. <br /> H M 1426 4/72 1M CO <br />