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L� <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOU ,�,­O!�UCE USE: 1601 E. Hazelton Ave. , Stockton- Calif. <br /> Telephone: (209) 466-67$1 .,., <br /> r— IAPPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. z - s—_2 /k� <br /> 73 - 6 33 d° <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued �p �3 <br /> - -(Complete In Triplicate) <br /> Application is hereby made t�o 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 and the Rules and Regula ons of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION �r J 1.� t -� CENSUS TRACT , <br /> Owner's Name Phonf <br /> Address -� °"`j' City �2 6 �� <br /> Contractor's Name j1, License'/ '-)-3 Phon4/ <br /> - <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN '/_7 RECONDITION / / DESTRUCTION.f7� <br /> PUMP INSTALLATION J J PUMP REPAIR I J PUMP REPLACEMENT <br /> 0 they. I <br /> 5 �} <br /> DISTANCE TO NEAREST: SEPTIC TANK `J SEWER LINES -PIT PRIVY e <br /> SEWAGE DISPOSAL FIELD_ _ CESSPOOL/SEEPAGE PIT OTHER. <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFIC ,Tios �v <br /> Industrial Cable Tool Dia. of ,Well Excavation <br /> `7C Domestic/private t Drilled Dia: of. Well"Casing (� <br /> Domestic/public I Driven Gauge .of C,4sing f s <br /> Irrigation Gravel Pack (Depth of Grout -Seal <br /> Other Rotary Type of Grout __ <br /> Other Other-Information <br /> PUMP INSTALLATION: Contractor <br /> r ,TYPe..;of Pump_..... - H.P. <br /> PUMP REPLACEMENT: State Work Done /` � , <br /> PUMP 'REPAIR: / / State Work Done _ <br /> R DFRTRUCTION OF WELL WellDiame"iii7' - - �- Approximate Depth <br /> Describe Material and Procedure <br /> 5 <br /> I hereby agtee to comply;with all laws and regulations of the San Joaquin Local.Health District <br /> and the State of Californiaypertaining to or regulating well"donstruction. Within FIFTEEN" DAYS <br /> after completion of my work on a new well, I will furnish the San Joaquin tocal Health District a . <br /> 14ELL 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 _ TITLEL <br /> t (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR -DEPARTMENT USE ONLY <br /> PHASE I f <br /> APPLICATION ACCEPTEDX E / a �S✓7 3 <br /> ADDITIONAL COMMENTS - &1ZI - <br /> PHASE II GROUT •INSPECTIONP S INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> .. CALL .FOR,A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INS 7/7/ <br /> E H 1425 C�/731M <br />