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I <br /> SAN, JOAgUIN LOCAL HEALTH DISTRICT .kk-0[IQ 3 <br /> FO OFFICE USE: 1601 E: Hazelton Ave. , Stockton, Calif. <br /> Telephone' : '� <br /> (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ILL10 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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 Ithe Rules and Regulations. ,of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION (J %� / <br /> r-/ � G �`t CENSUS TRACT <br /> Owner's Nam Phone! ,Z- <br /> Address 1170 e,- City ��1--� <br /> Contractor's Name y / All 22 A License Illu PIZ,PZ Phone 6 22 �f <br /> TYPE OF WORKeck) . NEW WELL Ch /�E _._ �—......R .. •-- ,_._ <br /> ( _ "'DEEPEN /_/ RECONDITION /-7 DESTRUCTION /? <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 QF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation {T$ <br /> Domestic/private Drilled Dia. of Well Casing <br /> �W Domestic/public Driven Gauge of Casing Z <br /> Irrigation Gravel Pack Depth of Grout• Seal r <br /> Other E Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor t <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / 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 C <br /> TITLE eA - <br /> (DRAW PLOT PLAN ON REVERSE SIDE) _ <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY "-"- DATE <br /> ADDITIONAL COMMENTS: f - .— <br /> PHASE II GROUT INSPECTION PHA III FINAL, INSPECTION <br /> INSPECTION BY-ixaz DATE a INSPECTION BY ATE <br /> a — <br /> CALL FOR OUT INSPECTION PRIG TO GROUTING AND FINAL INSPECT ON. <br /> E H 1426 7/72 1M <br />