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Z�Z-���SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOI'.:OFFICE U 1601 E. Hazelton Ave. , Stockton, Calif. <br /> 4 Telephone: (209) 466-6781 _ <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 75 33� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made I 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 aid the Rules and Regulations of- the San Joaquin Local Iieolth District. <br /> JOB ADDRESS/LOCATION _/e) f.`� l /J�/ i �,f Cv CENSUS TRACT <br /> Owner's Name 14lC- Phone <br /> Address -/to f / <7`!_ C`1 Y_ 7, City .r <br /> e <br /> Contractor's Name �.. License Phone 21 <br /> f <br /> TYPE OF WORK (Check) :. NEW WELL/ / DEEPEN /_/ RECONDITION /—/ DESTRUCTION /-7 <br /> PUMP k'INSTA LATION / / PL"MP REPAIR / / PUMP REPLACEMENT <br /> Other /-7 <br /> DISTANCE TO NEAREST: SEPTIC TANS: SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER \ <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS Q <br /> Industrial Cable Tool Dia. of Well Excavation �. <br /> Domestic/private i ,—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 /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: State Work Done <br /> i PUMP 2EPAIR: / / State Work Done <br /> DF-,TRUCTION 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 E <br />:i (DRAWK07 PLAK ON EVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PiiASE I <br /> r <br /> APPLICATION ACCEPTED BY DATE _ <br /> ADDITIONAL COrZIENTS: <br /> PHASE II GROUTiINSPECTION PHASE /FiNa INSPECTION <br /> INSPECTION BY 4DATE INSPECTION B`l ATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> F. H IL26 gi/711m <br />