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Y ~a <br /> SAN JOA(}UIN LOCAL HEALTH DISTRICT <br /> FOF- 61 ICE USL 1601 E. Hazelton Ave. , Stockton, Calif. <br /> F - Telephone: (209) 466---6781 <br /> — APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.73_Sy�`� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -3 <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 No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> . <br /> JOB ADDRESS/LOCATION ((1 �� e i CENSUS TRACT <br /> Owner's Name Ad t4tfi 44<i Phone <br /> Address .52 IlCity <br /> Contractor's Name �- License # Phone L <br /> TYPE OF WORK (Check) : NEW WELL _L!' DEEPEN '/—/ RECONDITION_/ / DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> Other /-7 <br /> DISTANCE TO NEAREST: SEPTIC TANK _5-.Or SEWER LINES cgp PIT PRIVY ;< <br /> XSEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS V <br /> Industrial _ Cable Tool Dia. of Well Excavation /,Oz/ NJ <br /> Domestic/private Drilled Dia. of Well. Casing a <br /> Domestic/public _ Driven Gauge of Casing IC2 CR <br /> Irrigation Gravel Pack Depth of Grout Sea] <<jQ ` -- _---\ <br /> Other Z Rotary Type of Grout �pl� O/J/'f��T _ - _ <br /> Other tither Information <br /> t PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: L/ State Work Done <br /> PUMP `tEPAIR: / / State Work Done <br /> ,DFgTRUCTION 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 b t of my knoVledge and belief. <br /> SIGNED TITLE <br /> (DLt& PAT PLAN ON REVERSE SIDE) <br /> R DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY _ DATE Zg2nl4L'20_ <br /> ADDITIONAL COMMENTS: --- <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE ' ` INSPECTION BY DATE Jr-� <br /> CALL VOIA�- •GRODg�I13SI'EC�ION-'PiZYD�TOcGROUTING-AND -F NAL--INSPECTION-.- <br /> E <br /> NSPECTION.E H 1426 _ r 5/731M <br />