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_C.�.. SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO ..OFFICL USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Z&- 7 Z, <br /> THIS PERMIT EXPIRES I. YEAR FROM DATE 'ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made. to the San Joaquin Local Health District for a Permit to construct <br /> and/or install the work hereip described. - This application is made in compliance with San Joaquin <br /> County Ordinance No, 1862 and,; the Rules and Regulations of the San Joauin Local Health District. <br /> t.(e 5'� S' ��• ��S�,�.'�` • <br /> JOB ADDRESS/LOCATION CENSUS TRACT Y� o <br /> Owner's Name Phone <br /> Address City <br /> Contractor's Dame License 4 !f9.1 r76.) Phone `tom! y6, s <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN '/ / rRECONDITION /_/ DESTRUCTION ./? <br /> MP <br /> PUMP INSTALLATION / / PUREPAIR'/ / PUMP REPLACEMENT ITT <br /> Other — <br /> t <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY y <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> C <br /> 1 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial I Cable Tool Dia. of Well Excavation <br /> Domestic/private 1 Drilled _ Dia. of Well Casing _ <br /> Domestic/public I Driven Gauge of Casing` <br /> Irrigation I Gravel Pack Depth of Grout Seal <br /> '. Other t Rotary Type of Grout <br /> I Other Other Information <br /> PUMP INSTALLATION: Contractor '~ <br /> Type ' f Pump ~ ---- H.P. \ <br /> r <br /> PUMP REPLACEMENT., / / State Work Done <br /> PUMP `tEPAIR: /LV..:State Work Done _ � <br /> DFCTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure — f <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 m work on a new well I will furnish the San Joaquin Local Health District a ! <br /> P Y � � <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 /> j SIGNED -, C TITLEaa+hC <br /> {DRAW'PLO PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED .BY f- DATE //-2, <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT .INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> ,SCALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 5/731M <br />