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iM <br /> C SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 1-3- -2-.2-19 ! <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 fo 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. 1861:2 andFthe Rules and Regulations of the San-Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION �C ' f 7 D / � CENSUS TRACT <br /> CT <br /> Phone <br /> Owner's Name Zee� j --- <br /> "!� --- <br /> Address. ��.3D © City <br /> Contractor's Name -AEIcense #J? Phone 3 <br /> �M P _ <br /> TYPE OF WORK. {Check) : NEW WELL /� DEEPEN /_/ RECONDITION /_� DESTRUCTION /� t <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> Other s/ / <br /> t � <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SIWAGEjDISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER .' <br /> !! k <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well. Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation f Gravel Pack Depth of Grout Seal <br /> Other i Rotary Type of Grout <br /> IM 1 Other Other Information e <br /> PUMP INSTALLATION: Contractor <br /> H.P. <br /> Type if Pump <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 /> I <br /> SIGNED ! ¢ cif"mac TITLE GlrtL� �t�c. <br /> 1� (Dkt& PCOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> � PHASE I �N � - - <br /> APPLICATION ACCEPTED BYDATE �_2_ <br /> iADDIT10NAL COMMENTS: I i <br /> PHASE II V INSPECTION PHA E III/FINAL INSPECTION <br /> INSPECTION BY .: DATE INSPECTION BY DATE o <br /> y <br /> CALL FOR A GROUT .INSlPECTION PRIOR TO GROUTING AND FINAL INSPECTION. 7/72 1M <br /> E H 1426 11 <br />