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�•�'"` Al� " ' <br /> a SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> rO£.:OF;FICE USE: 1601 E. Hazelton Ave: , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 73-S77 <br /> THIS PERMIT EXPIRES .I YEAR FROM DATE ISSUED Date Issued ALL-r--_Z3 <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 herein described. ' This application is made in compliance with San Joaquin <br /> County Ordinance .Na:: 1$62. and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION I CENSUS TRACT (061 �s a-rte <br /> Owner's Name Phone3( .-�� <br /> ,Addresses =V;J , �� � c-r A� --- City,_ . <br /> Contractor's Name IR` -_ License �LG3Phone7545 3�3 7 <br /> TYPE OF WORK (Check) : NEW WELL/. _ , DEEPEN / J RECONDITION DESTRUCTION <br /> DESTRUCTION <br /> PUMP INSTALLATION / / PL`MP REPAIR '/ / PUMP REPLACEMENT /_ <br /> Otherk/—/ I <br /> DISTANCE TO NEAREST: SEPTIC] TANK f_I—_�i SEWER LINES PIT PRIVY h <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER F { <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS 1 <br /> Industrial ! marble Tool Dia. of Well Excavation <br /> �Iromestic/private Drilled Iiia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> ` - Irrigation" `r .�Gravel Pack --Depth of Grout Seal <br /> Other i Rotary Type of Grout <br /> .t <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type sof Pump H P. <br /> PUTT REPLACEMENT: / / State Work Done <br /> PUMP UPAIRt ."..."`. / / Siate�Work"IDhe <br /> DFTRUCTION OF WELL <br /> ,c Well Diameter Approximate Depth <br /> . <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 <br /> the best of my knowledge and belief. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> k; PHASE I <br /> APPLICATION ACCEPTED .BY DATE <br /> f ADDITIONAL COMtiIENTS: <br /> PHASE II -GROUT INSPECTION PHASE II/FINAL INSPECTION <br /> INSPECTION BY kDATE �-�� INSPECTION BY DATE — - ' <br /> CALL FORA GROUT-INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. {� <br /> 5/731M <br />