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lie <br /> T` SAN J AQ� LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: . (209)' 466-6781 '(3 <br /> FFLt ATION FOR WE'LL CONSTRUCTION OR PUMP PERMIT Permit No. 7 L Z q I <br /> THIS PERMIT EXPIRES l YEAR FROM "DATE 'ISSUED Date Issued -ZS"-7,?, <br /> (Complete In Triplicate) <br /> Application"`i�'hereby made-to the Sam•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,40rdinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADrDRESS/LOCATION�V- iq,& c � °/v �' �� CENSUS TRACT <br /> Phone <br /> Owner''s <br /> Name <br /> city - Ii <br /> Address /I _. f� i <br /> _ _ , <br /> LicensePhone c ,0 � <br /> Contractor's .Name �L'1 <br /> TYPE OF WORK (Check): NEW WELL /� DEEPEN m/_� RECONDITION_/_� DESTRUCTION /7 <br /> PUMP INSTALLATION / I PUMP REPAIR '/�(/ PUMP REPLACEMENT <br /> /_7 <br /> Other <br /> f <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER: <br /> "INTENDED USE TYPE OF WELL <br /> CONSTRUCTION-SPECIFICATIONS � <br /> Industrial M Cable Tool Dia. of Well Excavation <br /> ..Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> ' Other Rotary Type of Grout r <br /> Other Other Informationm <br /> PUMP INSTALLATION: Contractor H.P. / ' <br /> Type of Pump f io <br /> r ' <br /> Pump !REPLACEMENT: / / State Work Done <br /> State Work Done �u tea- DY 'vn � c� !" ve tnti° +hofS <br /> � PUMP REPAIR: /?�/ <br /> ,PESTRUCTION OF WELL: Well Diameter - Approximate Depth _ <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regvlations of the ''San Joaquin 'Local Health District <br /> and the State of California pertaining to or regulating well cor►struction. Within FIFTEEN DAYS <br /> I after completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> WELLjDRILLERS 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.. , ti <br /> SIGNED Pte' - _ TIT _.� <br /> W (DRAW PLOT PLAN ON REVERSE IDE) <br /> FOR DEPARTMENT USE ONL <br /> i. <br /> PHASE I DATE S 7� <br /> APPLICATION ACCEPTED BY - • <br /> r ADDITIONAL COMMENTS: <br /> �I PHASE *. GROUT INSPECTION PHASE III FINAL INSPE!!6]n-22z!�7 <br /> ION <br /> INSPECTION BY DATE INSPECTION BY DATE Zi <br /> F CALL FOR A GROUT INSPECTION-PRIOR TO GROUTING AND FINAL INSPECTION. <br /> � -. <br /> 9 H 1426 . - 4172 1M <br />