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ZZ)/U S SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOL. OFFICE USI.:% 1601 E. Hazelton Ave. , Stockton, Calif. b P <br /> Telephone:11 (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.-7 " ��j'�W� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE -ISSUED Date Issued M <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 <br /> of the San Joaquin Local Health District. <br /> .TOB ADDRESS/LOCATION � d O �%mri��ir.�R�ix� /��'c�C� CENSUS TRACT ' <br /> Owner's Name ��'�� ''".� j Phone <br /> Address c' I cityjc <br /> Contractor's Name License J12 <br /> a7�7SF Phone <br /> TYPE OF WORK (Check) : NEW WELL . DEEPEN `j/ / RECONDITION_/ / DESTRUCTION f7 <br /> PUMP INSTLATION ` PUI�fP REPAIR / / PUMP REPLACEMENT /� <br /> AL <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELDIJ CESSPOOL/SEEPAGE PIT OTHER <br /> �M <br /> INTENDED USE TYPE OF WELL i CONSTRUCTION SPECIFICATIONS �s <br /> Industrial Cable Tool Dia'. of Well Excavation Z67 0SN� <br /> >( Domestic/private Drilled �� Dia. of Well Casing <br /> Domestic/public Driven j Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other X Rotary Type of Grout <br /> Other Other Information . <br /> PUMP INSTALLATION: Contractor .' <br /> Type of Pump } H.P. <br /> PUMA' REPLACEMENT: / / State Work Done. <br /> _ c <br /> j. <br /> PUMP UPAIR: / / State Work Done <br /> .DFRTRUCTION 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 REPO f the well and notify1�them before putting the well in use. The above <br /> information is ue to _ t of y knowledge and belief. <br /> e SIGNED TITL <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY , <br /> PHASE I <br />` APPLICATION ACCEPTED .BY DATE Q 7 / <br />' ADDITIONAL COUNTS: EI <br /> PHASE.Jy GROU NSPECTION t P S I /FIN INSPECTION <br /> INSPECTION BY ATE r INSPECTION B DATE <br /> 001, <br /> CALL YOR A-GROUT INSPEC ON PRIOR TO GROEUTING AND FINAL INSPECTION. <br /> , ,.. /7 <br /> . ,, 0 <br />