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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFI USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 73 3p� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 6_,z/, _ <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permitto construct <br /> and/or install the work herein described. This application is made in compliance with San Joa, <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health Distric <br /> JOB ADDRESS/LOCATION =I aaenic9?13 1 � � . <br /> i'I. . Ts CENSUS TRACT <br /> Owner's Name _ W L T— <br /> Phone <br /> Address /.] Q2 ef/2f- <br /> City 5j6C/ts0/Y <br /> Contractor's Name CZARI 4A/ 'l-4 C G License !I �GOZ Phone <br /> TYPE OF WORK (Check) : NEW WELL /V DEEPEN /_% RECONDITION /-7 DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other / / — <br /> DISTANCE TO NEAREST: SEPTIC TANK U SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> I <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial �- Cable Tool Dia, of Well Excavation y <br /> Domestic/private 'I Drilled <br /> -)_ Domestic/public of Well Casing <br /> Driven Gauge of Casing <br /> Irrigation M Gravel Pack Depth of Grout Seal S� <br /> Other Rotary Type of Grout G Y <br /> Other Other Information <br /> CL<f9Fiy7 <br /> i <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H P <br /> PUMP REPLACEMENT: State Work Done <br /> PUMP 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 regulationsof theSanJoaquin 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 <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 L^ TITLE <br /> (DRAW PLOT PLAN ON REVE <br /> PHASE I RSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY �� > DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPE TION PHASE III FINAL INSPECTIO <br /> INSPECTION BY DATE �7��j�,``INSPECTION B� DATE /l 7 <br /> CALL FOR A GRO T INSPECTION P R T0trCR Ib0AND FINAL INSPEC ON. AA Al <br />