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61-7f <br /> I JOAQUIN LOCAL HEALTH DISTRIC' NNE® <br /> F170—r. OI FICR USE: 16C_ E. Hazelton Ave. , Stockton, Calif. <br /> f Telephone: (209) 466-6781 <br /> PLICATION FOR WELL.CONSTRUCTION OR PUMP PERMIT Permit No. 3 r <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued �[ r <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 Joaquir <br /> County Ordinance No. 1862 and the: Rules and Regulations of the Sats Joaquin Local. health District. <br /> .TOB ADDRESS/LOCATION V300 . C D fiD t=d C-e j!E1fiNSUS TRACT <br /> Owner's Name C Phone <br /> Address 3 01a City , ;GL <br /> Contractor`s Name -. � � License #,2 Phone: <br /> 7 <br /> TYPE OF WORK (Check.): NEW WELL /? DEEPEN / / RECONDITION / / _ DESTRUCTION /_7 - <br /> PUMP INSTALLATION 15? PUMP REPAIR':/—/ PUMP REPLACEMENT 17 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TAINK je-pl SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER p <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS G <br /> Industrial Cable Tool' Dia. of Well Excavation lt� <br /> - _x Domestic/private Drilled Dia. of Well Casing C <br /> Domestic/public Driven Gduge of Casing �y <br /> Irrigation crewel Pack Depth of Grout Seal` <br /> Other Rotary Type of Grout...:,.._.' <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor �-X�'� <br /> Type of Pumg � H.P. !® <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP VPAIR: / / State Work Done <br /> .DFe-TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material, and Procedure t. =` <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 46AZLI.- ITLE <br /> (DRAW PL AN ON REVERSE SIDE) <br /> FOif DEPARTMENT USE ONLY <br /> PHASE I / <br /> APPLICATION ACCEPTED Bl�_?, WlextDATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASELII/FINAL INSPE TION ' <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. �l <br />