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-- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT E <br /> FOR FICE USE: 1601 E. Hazelton Ave, , Stockton, Calif. <br /> N <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ,7 33p <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) 00 <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 /> County Ordinance.-NP. 1862 andlthe. ?,ules and Regulations of the San Joaquin Local Health District. <br /> i <br /> JOB ADDRESS/LOCATIONrc CENSUS TRACT <br /> r <br /> /� � S <br /> Owner's dame /Kim-G Phone 3� � t{_ V_7� _. }}•. <br /> Address if". d . [.� cityc` <br /> Contractor's Name llJ - License �� �3) Phan -12 <br /> e��, <br /> ^TYPE OF WORK (Check) : . NEW WELL /-7 DEEPEN / / RECONDITION /� DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY l <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER i <br /> I W'' <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 � _ TI <br /> _ Irrigation t --. .Gravel Pack - 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: Skate Work Done P�,(,�' p•c{,�°` Cfj <br /> PUMP REPAIR. / / State Work Done <br /> ,RESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe'Material and Procedure <br /> 1 - <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 /> (DRA LOT PLAN ON REVERSE SIDE <br /> OR DEPARTMENT USE ONLY <br /> PHASE I _ <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> t PHASE II "0 P I .k PHASE •III/FINAL INSPECTION <br /> INSPECTION BY ATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. ' ' <br /> E H 1426 7/72 1M <br />