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a � <br /> Z1601 <br /> SAN. JOAQUIN LOCAL HEALTH DISTRICT <br /> ML;OIFICE USE: E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (204) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 73 <br /> THIS PERMIT EXPIRES I. YEAR FROM DATE. ISSUED Date Issued <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 Joaquin: <br /> County Ordinance Ido: 1.862 and the Rules and Regulations of the San Joaquin Local: Health District. <br /> { I CENSUS TRACT <br /> JOB ADDRESS/LOCATION ' <br /> Owner's Name _ �i�Jvt, C_.1�aln0 I o'ylJ� � Phone <br /> Address -gumCity ' '(3 .. <br /> Contractor's Name t� License # hone g~ / <br />'F TYPE OF WORK (Check) : NEW -WELL/ / DEEPEN '/ / RECONDITION"/ / DESTRUCTION <br /> PUMP 'INSTALLATION / / PIMP REPAIR '/ / PUMP REPLACEMENT <br /> I other/ / <br /> . DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY � <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER V <br /> INTENDED USE ITYPE OF WELL w 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 — Gravel Pack Depth of Grout Seal. <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> k <br /> PUMP INSTALLATION: Contractor <br /> Types of Pump H.P. / <br /> PUMP REPLACEMENT: /r State idork Done ? D . A <br /> { r <br /> PUMP UPAIR: / -/- State Work Done <br /> i <br /> '} DFQTRUCTION 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 /> j WELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> �f <br /> information is true .to the best of my wled e a elief. <br /> SIGNED ITLE <br /> _r (D Ld P 0 A1V ON RE RSE SIDE - <br /> R DEPARTMENT USE ONLY <br /> f PHASE I DATE <br /> ,1 APPLICATION ACCEPTED BY -- <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTIONPHA E IIT FINAL INSPECTIO <br /> 3, <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> 'CAL L FOR-A GR011"' INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> � :: LYm_... � _ 5/731M <br />