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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 3-3' !z) <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ZS-.23(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 herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862the Rules and Regulations of the San Joaquin Local Health District. <br /> S'r ©� <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name ZY�} % Phonec _c26L7 <br /> Address ;�A <br /> / • City l`yU4-14 ie./c/ .- . <br /> Contractor's Name _� ( /�/ �p � �/�L`�fry � cense # Phone �(�,SL <br /> ci <br /> TYPE OF WORK (Check) : NEW WELL IV DEEPEN / j RECONDITION /-7 DESTRUCTION /'j <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /-7 <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 �JC� �i <br /> X Irrigation X Gravel Pack Depth of Grout Seal -•__-_ <br /> Other �� Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: <br /> 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 /> 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 a <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 .n TITLE <br /> ADAAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE /-_;?3 ::�2 2 <br /> ADDITIONAL COMMENTS: / <br /> PHASE II G NWCTIM P E III F AL INSPECTION <br /> INSPECTION BY DATE INSPECTIO BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> 1426 7172 1M <br />