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zV <br /> SAN OAQUA - OCAL HEALTH DIST ACT <br /> 'FOF.:OFkICL' USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> G APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit <br /> 1 76-SOS- <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued �5 <br /> I (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 /> ECounty Ordinance :No.: 1$62 and the Rules and Regulations of the San Joaquin Local: Health District. <br /> t <br /> JOB ADDRESS/LOCATION 7 A44CENSUS TRACT . <br /> Owner's Name �7Phone <br /> Address / ' r.�r�� <br /> City.. <br /> Contractor's Namei License �� honq � <br /> 1 <br /> r <br /> TYPE OF WORK (Check) : NEW WELL ' DEEPEN / / RECONDITION / / DESTRUCTION /_7til <br /> PUMP .INST TION PUMP REPAIR /—/—PUMP REPLACEMENT /_ <br /> Other <br /> _ 1 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER .LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER \ <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation Q <br /> A(Domestic/private I ' V'Driiled Dia. of Well. Casing <br /> Domestic/public # Driven Gauge of Casing <br /> Irrigation [ Gravel Pack Depth of Grout Seal <br /> Other 1 Rotary Type of Grout <br /> i Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type 'of Pump H.p. <br /> PUMP REPLACEMENT: / J State Work Done <br /> PUMP 'REPAIR: / / State Work Done - <br /> ,DF�TRUCTION 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 TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) -- . - ----- <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTER .BY DATE ZZO�� <br /> ADDITIONAL COMMENTS: � <br /> PHASE A ROUT INSPECTION PHAS I/FIN INSPECTION <br /> INSPECTION.BY DATE Zl-Z2,ZK INSPECTION BY DATE <br /> CALL FOR A GROUT, INSPE9fION PRIOR TO GROUTING AND FINAL INSPECTION. ` <br /> E H 1426 � /7�•su + <br />