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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFtICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> a <br /> f Telephone : (209) 466-6781 <br /> ! APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. _� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued. L-ZS--�3 <br /> (Complete In Triplicate) 2-05-f(,v 0 7 <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 San Joaquin Local Health District. <br /> ,.To3Rs s..` kJ C�/,� Z, <br /> JOB ADDRESS/LOCATIONSSCkgIr ` '�/ CENSUS TRACT ` <br /> Owner's Name 0 Pone <br /> Addressr NISI ,QEA1V14^/1 - <br /> City <br /> Contractor's Name License #Z 121 <br /> w_- - - - <br /> TYPE OF WORK (Check): NEW WELL /-7DEEPEN % /'k RECONDITION /- DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR /PUMP REPLACEMENT /-7 <br /> Other �4 - <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER L NES PIT PRIVY l <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER . <br /> INTENDED USE STYPE OF .WELL_. <br /> CONSTRUCTION <br /> SPECIFICATIONS <br /> Industrial ':r. Cab le`�Tool Dia. of Well Excavation,`, <br /> Domestic/private Drilled Dia. of Well Casing <br /> ' Domestic/public Biiven Gauge of Casing f <br /> Irrigation Gravel Pack_ Depth of Grout Seal 111 <br /> Other Rotary Pick------ <br /> of Grout <br /> Other Other Information ..; <br /> PUMP INSTALLATION: Contractor <br /> t� <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: /-7 State Work Done <br />-PUMP-REPAIR: .�- _ -7-�!' i - - - <br /> /f�°lStateWor1 Done <br /> tESTRUCTION OF WELL: Well Diameter I Approximate Depth <br />[ Describe Material and Procedure <br /> Thereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> kand 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 theta before putting the well in use. The above <br /> information true-to a be t of my knowledge and belief. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE I FPR DEP NT USE ONLY <br /> APPLICATION ACCEPTED B , DATE Z S J <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAW 4,II/FWAL INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECT N. <br /> E H 1426 �.t 7/72 1M <br />