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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> r70f. OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WEEL CONSTRUCTION OR PUMP PERMIT o. 71�_ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued Ig <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 J©aquina <br /> ' County Ordinance N 186 the Rules and .Regulations of the San Joaquin Local Heath District. <br /> JOB ADDRESS/LOCATIONf / ,--�� <br /> CENSUS TRACT � <br /> Owner's Namej� fr,� � -- �/5/;c�� PhoneT"`J/- 7' <br /> Addres � ZJ_ �..... �© G`��.... �� CitylC>�� 1� <br /> Contractor's Name License # Phone 9 46 , { <br /> _.. <br /> TYPE OF WORK (Check) : NEW WELL _ .DEEPEN '/ J RECONDITION /_/ DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR'/ / PUMP REPLACEMENT <br /> Other / / <br /> 1 .— F <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES . PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> N., <br /> INTENDED USE TYPE OF WELL f CONSTRUCTION SPECIFICA IO S <br /> Industrial Cable Tool., Dia. 8f Well Excavation / u 4 <br /> Domestic/private Drilled . �-- - Dia. -o�f Well Casing <br /> Dourest /public Driven Gauge of Casing / � a <br /> Irrigat;lon Gravel Pack t Depth of Grout Seal <br /> Other \. Rotary = ' Type of Grout ->-� <br /> Other ='�Other. Information <br /> PUMP INSTALLATION: . Contractor <br /> Type of Pump H.P, . <br /> PUMP REPLACEMENT: State Work Do <br />'�"' PUMP 'tEPAIR: -~ <br /> State LJork Done <br /> / 1/ <br /> DFfiT_RUCTION OF WELL. Well,Diameter Ca � Approxiniate Depth <br /> Describe fiteriil and P ocedure' <br /> • �/`� t ti <br /> I hereby agree to comp with ail laws and regulations of the San Joaquin Loc Health District s ..y <br /> and, the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS. f <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. x <br /> SIGNED Yr1• �,�, TITLE <br /> (DRAW PLOT <br /> ILAN ON REVERSE.SIDE <br /> "PHASE I FOR DEPARTMENT USE ONLY <br /> �� <br /> APPLICATION ACCEPTED .BY o. . DATE <br /> ADDITIONAL. COMMENTS: <br /> ' I'LLASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY, DATE INSPECTION BY DATE <br /> CALL! FOR.-A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION } <br /> E Hyp 1426mow. <br /> r- Ate.`_"" :�Z31M <br />