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IT <br /> SAN JOA UIN LOCAL REALTH DISTRICT <br /> r t. <br /> FOR OFFICE USE: 1601 E. Hazelton. Ave. , Stockton, Cali.' <br /> Telephone: (205) 466-6781 ' <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> f <br /> 1 <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 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 No. 1862 and. the Rules and Regulations of the Sawn :Toaquin Local Health District. <br /> JOB ADDRESS/LOCATION D2-0 1509 rz:P CENSUS TRACT �G - <br /> Phone <br /> y <br /> owner's Name <br /> �/�� <br /> Address Yltf�l7 1 V�A�.. ���3 city <br /> Contractor`s Name7�iS�/�+�1$�✓ � License #4.29a�,,r�Phonez <br /> i <br /> r� TYPE OF WORK (Check) : NEW WELL '/ -/ -DEEPEN / / RECONDITION DESTRUCTION /_7 <br /> f PUMP INSTALLATION �I'PUMP REPAIR / / PUMP REPLACEMENT /� <br /> } Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL -FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> " INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS Its <br /> � Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia,. of Well Casing C <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 /> 1 <br /> PUMP INSTALLATION: Contractor S 7 4w 6 <br /> H.P. <br /> Type of Pump e,rr2 4& S <br /> 7sj <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> ;DESTRUCTION OF ELL: Well Diameter T Approximate Depth <br /> Describe Material and Procedure <br /> j I hereby agree to. comply with all laws and regulations of the San Joaquin Local Health District, <br /> r 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 /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY ➢ATEC ' a <br /> ADDITIONAL COMMENTS: �j - _V_ <br /> PHASE II GROUT INSPECTION PHASE Ii FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE/IS --,,4,3 <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL.-INSPECTION. <br /> E H 1426 4/72 1M _. <br />