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/ f SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> i0_1 OFFICE USL: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. S 3 F&) <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -2 <br /> (Complete In Triplicate) y <br /> Application is hereby made to the San Joaquin Local Health Distract for a permit to construct <br /> and/or install the work herein described. - Th3s application is made in compliance with San-Joaquin <br /> County Ordinan No 18 2 and the Rules and Regulations of the San Joaquin Local Health Distract. <br /> 4 - � Ae C <br /> JOB ADDDRES9/LLOCATIONA -Z,;:: Zia - J <br /> CENSUS TRACT <br /> 4 Owner's Name Pz".--, <br /> Phone 7C � <br /> Address <br /> Cityl <br /> Contractor's Name License lF Phone <br /> TYPE OF WORK (Check) : NEW WELL lj�r; DEEPEN '/ / RECONDZTiON /�./ DESTRUCTION /-7._ <br /> �. PUMP INSTALLATION /2;�- 'p. Np REPAIR <br /> Other/ / PUMP REPLACEMENT <br /> DISTANCE T0 'NEAREST: SEPTIC TAN EWER L NE -f--PIT PRIVY <br /> F SEWAGE DISPOSAL FIE ESSPOOL/SEEPAGE PIT THERE <br /> L <br /> INTENDED USE it TYPE OF WELL <br /> 'CONSTRUCTION SPECIFICATIONS j <br /> In <br /> Siustrial Cable Tool \Dia, of Well Excavation. A3 <br /> Domestic/private �Dzilled � Dia. of Well,Casing <br /> Domestic/public ,, Driven* Gauge-of Casing <br /> Irrigation Gravel Pack Depth of Grout 11 <br /> Othe otar 4Z.�{,� �?- <br /> � Y Type of Grout �14 �- <br /> Ir <br /> f �o <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor �- y <br /> Type of P H.P. '7/ <br /> PUMP REf A'CEMEXT: /r' / State Work Done <br /> PUMP ' AIR,:;. ` Z?. <br /> State Work Done <br /> ,DF'ZTRUCTION OF WELL: Well Diameter <br /> approximate Depth 4 = <br /> Describe Materia 'and Procedure/. <br /> I hereby agree to cbmply ;wi.th all laws andregulations 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`ithe well and notify them before putting the well in use. The above <br /> info ationTis,.true to the b my knowledge and belief. <br /> SIGNED TITLE <br /> <- C,cur��� —. <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> R DEPARTMENT,USE ONLY <br /> PHAS <br /> APPLICATIONACCEPTED -BY :i - DATE <br /> ADDITIONAL COMMENTS: ) � <br /> PHASE II GRI INSPECTION _PHASE III/,FINAL 'INSPECTION <br /> INSPECTION BY DATE S INSPECTION BYDATE �. <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E'H _1426 /7�,.. <br />