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y. .� <br /> SAN JOA.QUIN LOCAL HEALTH DISTRICT <br /> FOR &FICE USE: 1601 E. Hazelton, Ave. , Stockton, Calif. �^ ��►�. .c <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Jam_ /O 34r/ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) 4�z� <br /> Application is hereby made to' the San Joaquin Local Health District for a peer it o construcC_ -� <br /> and/or install the work herein described. This application is made in compliance with--San Joaquin <br /> County Ordinance No. 1862 and'it//he Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION O/� h rTr cTo c�' gSaa CENSUS TRACT <br /> Owner's NameC'�r�,��;�,U Phone 4/,/..3 9.00 �' <br /> Address o/S 1-7-7-1 �= City -rz���crr�e� <br /> Contractor's Name /n- �( License # Phone <br /> I _�- Yom• ._. <br /> TYPE OF WORK (Check): NEW WELL /7 DEEPEN RECONDITION AL /_7 DESTRUCTION /_7 <br /> PUMP INS <br /> TLATION / / REPAIR / / PUMP REPLACEMENT /_7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK ' SEWER LINES PIT PRIVY <br /> w <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> C <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br />_ Industrial # Cable Tool Dia, of Well Excavation " " <br />_ x Domestic/private I Drilled Dia. of Well Casing G `' 70 r H <br /> Domestic/public I Driven Gauge of Casing 'J <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other _ Rotary Type of Grout <br /> I Other Other Information <br /> ;{ ` <br /> -4 <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 Diatmeter Approximate Depth <br /> Describe Material and Procedure <br />[ hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> and the State o€ 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 /> 4ELL 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, r <br />>IGNED TITLE owQ1 2 . <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br />'RASE I <br /> IPPLICATION ACCEPTED BY DATE G' <br /> 1DDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS III FINAL INSPECTION <br /> INSPECTION BY \ DATE INSPECTION BY DATE / <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTI01, <br /> EH126 ' <br /> .�,.� 7I72 IM . <br />