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f rt SAN JOAQUIN L6CAL HEALTH DISTRICT <br /> FOf. ,OFF ICE USI:: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> +. Telephone: (209) 466-67$1 <br /> APPLICATION FOR WELT, CONSTRUCTION OR PUMP PERMIT Permit No. 73�j�y✓' <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued /a -7r3 <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 wade in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District, <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name `- � �`� i�rC'a�' �? :% Phone <br /> Address City <br /> Contractor's Naivef 'sf �E'Jpi l�llG.�G �d License # Phone <br /> TYPE OF WORK (Check) : NEW WELL /-7 DEEPEN / / ,RECONDITION / / DESTRUCTION /-T <br /> PUMP INSTALLATION / / PUMP REPAIR /—/—PUMP REPLACEMENT /-7 <br /> OtherJ9 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT, PRIVY <br /> SEWAGE DISPOSAL FIELD " CESSPOOL/SEEPAGE PIT OTHER <br /> 4- <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation / <br /> Domestic/private � ` Drilled Dia, of Well Casing -Ao!l�7 <br /> i Domestic/public Driven Gauge of Casing _Ay�,f/-4S7 <br /> Irrigation Gravel Pack Depth of Grout Seal - <br /> - Other _S ��S�lle Rotary Type of Grout �rJ,tlE <br /> 7"��TZ- ��,G S Other Other Information �rE�� :2 E . <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> :f 'PUMP REPAIR: / / State Work Done ` <br /> f DFTRUGTION 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 /> t <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 o th best f my knowledge and belief. N(J McEZI -5 -13EiA1G G'OrVS7,�vcTc/�. <br /> E] <br /> `5 SIGNED TITLE A <br /> v (DRAW PLOT PLAN ON REVERSE SIDE) -- <br /> FOR DEPARTMENT USE ONLY <br /> a PHASE I <br /> APPLICATION ACCEPTED BY DATEZZAI <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHA <br /> E I I/FIN -INSPECTION <br /> INSPECTION BY IVDATE INSPECTION BY ATE /d <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br />,__- E H 1426 5/731M <br />