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"N JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE 4hereb <br /> 16Gvi. Hazelton Ave. , Stockton, Ca11-e. <br /> J/ Telephone: (209) 466-6781 <br /> P LIGATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued Q -/ 7 Y <br /> (Complete In Triplicate) <br /> Application de to theSan Joaquin Local Health District for a permit to construct <br /> .and/or install the work herein described. This application is made in with San Joaquii <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> _JOB ADDRESS/LOCATION 9�,$ 3 � y rA/VT p CENSUS TRACT <br /> Owner's Name �/ �� fOn �� ,i Phone <br /> -Address s =�= City � Ems ✓ <br /> Contractor's Name { X1 4 License #SCS" Phone <br /> TYPE OF WORK (Check) : NEW WELL /T DEEPEN /-7 RECONDITION /-T DESTRUCTION /- <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private 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 L/,/"V&yy yz <br /> Type of Pump _ 49'e i... H.P. � v <br /> PUMP REPLACEMENT: State Work Done <br /> T <br /> ?UMP REPAIR: / / State Work Done <br /> DESTRUCTION 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 /> ind the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> if ter completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> _.if <br /> WELL DRILLERS REPORT of the well and notify them before putting the wel in use. The above <br /> informatio is tr e t the best of my knowledge and belief. <br /> `SIGNED�2 ��� � TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> .CHASE I <br /> APPLICATION ACCEPTED BY DATE U <br /> WDITIONAL COMMENTS: <br /> _ PHASE II GROUT INSPECTION PHASE III INAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY T -7 <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 72 1M <br />