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ZIA kr?-It <br /> • ��-- � SAN ,?OAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. LJc't�y , ,f5 <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. "s <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made to'Ithe 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 CENSUS TRACT , <br /> �a- �..� �?�� � � -_-- _ . _ <br /> Owner r s Name Cz—_S d Y Phone <br /> r <br /> Address V, .-3 jAl_ r G f) W City <br /> .<-74L <br /> Contractor's Name License # Phone <br /> I <br /> TYPE OF WORK (Check): NEW WELL / / DEEPEN / / RECONDITION DESTRUCTION / <br /> PUMP INSTLATION / I PUMP REPAIR / / PUMP REPLACEMENT/� <br /> AL <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER 4 <br /> A _ <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS CA <br /> Industrial 1 Cable Tool Dia. of Well Excavation <br /> I` Domestic/private i Drilled Dia. of ;Well Casing <br /> Domestic/public � � <br /> Driven Gauge of Casing <br /> I <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> 1 Other Other Information <br /> :J <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. ^ <br /> F PUMP REPLACEMENT: / / State Work bone <br /> PUMP REPAIR: / / State Work Done <br />, ,DESTRUCTION OF WELL: Well Diameter Approximate DepthQ <br /> Describe Material and Pro edure <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 .Wof the well and notify them before putting the well in use. The above <br /> information is true to the best of my knowledg and belief. <br /> SIGNED r TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> ' APPLICATION ACCEPTED BY . DATE '7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT NSPECTION PHA, III FIN INSPECTIO <br /> tINSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO .GROUTING AND FINAL INSPECTI . <br /> E H1426 7/72 IM/4) <br />