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y <br /> _ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 6 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Z SD 4J <br /> THIS PERMIT EXPIRES 1. !EAR FROM DATE ISSUED Date Issued <br /> .z-7- <br /> (Complete In Triplicate) <br /> Application is hereb made to the San Joaquin Local Health District for a <br /> Y� q 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't e Rules and Regulations of the San Joaquin Local Realth District. i <br /> .TOB ADviDRESS/LOCATION CENSUS TRACT ff� <br /> Owner's Name Phone 227L,2_5 `Y. <br /> AddressOKCity <br /> Contractor's Name Lcense 'Pho <br /> TYPE OF WORK (Check) : NEW WELL /W DEEPEN /_/ RECONDITION /_/ DESTRUCTION /_7 <br /> PUMP INSTILLATION J / PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> ( Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER o� <br /> INTENDED USE TYPE OF WELL_ CONSTRUCTION SPECIFICATIONS \' <br /> Industrial. _ Cable Tool Dia.. of Well Excavation <br /> Dome stic/private Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> �( Irrigation Gravel Pack Depth of Grout Seal <br /> T' Other notary Type of Grout �4 �T <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of PUMP H.P. <br /> PU �?t' 0�N�f� c <br /> / f State 'Work D , <br /> PUMPREPLACEMENT: / / State Work Done <br /> .. <br /> ,DF'QTRUCTION 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 /> SIGNED _ j TITLE <br /> (D PLOT PLAN ON REVERSE SIDS _ <br /> —T FOR DEPARTMENT USE ONLY <br /> PHASE I 01 <br /> APPLICATION ACCEPTED .B __/ DATE] <br /> ADDITIONAL COMMENTS: ti:� -`- 1_-_ b <br /> PHASE 71 GROU INSPECTION PHAS II/FINAL INSPECTION , / <br /> INSPECTION BY ri/ DATE = 0-7� INSPECTION BY DATE - -`7(� <br /> CALL FOR A GROUT INSPE TION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 5/731M <br />