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SAN JOAWIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE 1601 E. Hazelton Ave, ; Stockton,' Calif. <br /> Telephone: . (209) 466,-678l <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> 72--7 9 <br /> THIS PERMIT• EXPIRES 1 YEAR FROM:DATE ISSUED <br /> Date Issued � /- -7 <br /> - (Complete In Triplicate) <br /> Application is hereby de to the San.Joaquin Local Health District for a -permit to construct <br /> and/or install the w k erein described. This 'application is made in compliance with San Joaq <br /> County Ordinance -No.� 1862 nd the. Rules and Regulations of the San J a u n Local Health Distric <br /> JOB ADDRESS/LOCATION /&0 t�r�c��e,. � r� FIZo�� <br /> * C{Ytn : 'r/"� �: �_ N3US TRA <br /> CT <br /> Owner.'s Name: e- R �. , S 7/ <br /> T� Phone-If 411 6 L 3 % <br /> AddressY <br /> Contractor's Name iLLyt.� .�C�j� e � License #,QQ,kL- phone 464e gt <br /> TYPE OF WORK (Check) : NEW WEL011 DEEPEN 1-7 RECONDITION /7 DESTRUCTION /7 <br /> PUMP INS ATION / / PUMP REPAIR jP PUMP REPLACEMENT /_7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD,. n- CESSPOOL/SEEPAGE PIT OTHER <br /> 1 1 x . I <br /> INTENDED. USE TYPE OF WELL'1 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 i Gravel Pack Depth of Grout Seal <br /> ?a Other Rotary Type of Grout <br /> ,Other Other Information ' i <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump t;111Xf H.P. 1 <br /> PUMP REPLACEMENT: ° / / State Work Done <br /> PUMP REPAIR: State Work Done <br /> .pESTRUCTION OF WELL: Well Diameter i 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 F <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 toils -TITLE. <br /> (DRAT* <br /> P LOT LAN ON REVERSE SIDE) <br /> / <br /> -PHASE I FOR DEPARTMENT USE ONLY <br /> .'j l <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: U <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTIO34 <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTIO <br /> E H 1426 , _-- <br />